case study examples substance abuse

Module 9: Substance-Related and Addictive Disorders

Case studies: substance-abuse disorders, learning objectives.

• Identify substance abuse disorders in case studies

Case Study: Benny

The following story comes from Benny, a 28-year-old living in the Metro Detroit area, USA. Read through the interview as he recounts his experiences dealing with addiction and recovery.

Q : How long have you been in recovery?

Benny : I have been in recovery for nine years. My sobriety date is April 21, 2010.

Q: What can you tell us about the last months/years of your drinking before you gave up?

Benny : To sum it up, it was a living hell. Every day I would wake up and promise myself I would not drink that day and by the evening I was intoxicated once again. I was a hardcore drug user and excessively taking ADHD medication such as Adderall, Vyvance, and Ritalin. I would abuse pills throughout the day and take sedatives at night, whether it was alcohol or a benzodiazepine. During the last month of my drinking, I was detached from reality, friends, and family, but also myself. I was isolated in my dark, cold, dorm room and suffered from extreme paranoia for weeks. I gave up going to school and the only person I was in contact with was my drug dealer.

Q : What was the final straw that led you to get sober?

Benny : I had been to drug rehab before and always relapsed afterwards. There were many situations that I can consider the final straw that led me to sobriety. However, the most notable was on an overcast, chilly October day. I was on an Adderall bender. I didn’t rest or sleep for five days. One morning I took a handful of Adderall in an effort to take the pain of addiction away. I knew it wouldn’t, but I was seeking any sort of relief. The damage this dosage caused to my brain led to a drug-induced psychosis. I was having small hallucinations here and there from the chemicals and a lack of sleep, but this time was different. I was in my own reality and my heart was racing. I had an awful reaction. The hallucinations got so real and my heart rate was beyond thumping. That day I ended up in the psych ward with very little recollection of how I ended up there. I had never been so afraid in my life. I could have died and that was enough for me to want to change.

Q : How was it for you in the early days? What was most difficult?

Benny : I had a different experience than most do in early sobriety. I was stuck in a drug-induced psychosis for the first four months of sobriety. My life was consumed by Alcoholics Anonymous meetings every day and sometimes two a day. I found guidance, friendship, and strength through these meetings. To say early sobriety was fun and easy would be a lie. However, I did learn it was possible to live a life without the use of drugs and alcohol. I also learned how to have fun once again. The most difficult part about early sobriety was dealing with my emotions. Since I started using drugs and alcohol that is what I used to deal with my emotions. If I was happy I used, if I was sad I used, if I was anxious I used, and if I couldn’t handle a situation I used. Now that the drinking and drugs were out of my life, I had to find new ways to cope with my emotions. It was also very hard leaving my old friends in the past.

Q : What reaction did you get from family and friends when you started getting sober?

Benny : My family and close friends were very supportive of me while getting sober. Everyone close to me knew I had a problem and were more than grateful when I started recovery. At first they were very skeptical because of my history of relapsing after treatment. But once they realized I was serious this time around, I received nothing but loving support from everyone close to me. My mother was especially helpful as she stopped enabling my behavior and sought help through Alcoholics Anonymous. I have amazing relationships with everyone close to me in my life today.

Q : Have you ever experienced a relapse?

Benny : I experienced many relapses before actually surrendering. I was constantly in trouble as a teenager and tried quitting many times on my own. This always resulted in me going back to the drugs or alcohol. My first experience with trying to become sober, I was 15 years old. I failed and did not get sober until I was 19. Each time I relapsed my addiction got worse and worse. Each time I gave away my sobriety, the alcohol refunded my misery.

Q : How long did it take for things to start to calm down for you emotionally and physically?

Benny : Getting over the physical pain was less of a challenge. It only lasted a few weeks. The emotional pain took a long time to heal from. It wasn’t until at least six months into my sobriety that my emotions calmed down. I was so used to being numb all the time that when I was confronted by my emotions, I often freaked out and didn’t know how to handle it. However, after working through the 12 steps of AA, I quickly learned how to deal with my emotions without the aid of drugs or alcohol.

Q : How hard was it getting used to socializing sober?

Benny : It was very hard in the beginning. I had very low self-esteem and had an extremely hard time looking anyone in the eyes. But after practice, building up my self-esteem and going to AA meetings, I quickly learned how to socialize. I have always been a social person, so after building some confidence I had no issue at all. I went back to school right after I left drug rehab and got a degree in communications. Upon taking many communication classes, I became very comfortable socializing in any situation.

Q : Was there anything surprising that you learned about yourself when you stopped drinking?

Benny : There are surprises all the time. At first it was simple things, such as the ability to make people smile. Simple gifts in life such as cracking a joke to make someone laugh when they are having a bad day. I was surprised at the fact that people actually liked me when I wasn’t intoxicated. I used to think people only liked being around me because I was the life of the party or someone they could go to and score drugs from. But after gaining experience in sobriety, I learned that people actually enjoyed my company and I wasn’t the “prick” I thought I was. The most surprising thing I learned about myself is that I can do anything as long as I am sober and I have sufficient reason to do it.

Q : How did your life change?

Benny : I could write a book to fully answer this question. My life is 100 times different than it was nine years ago. I went from being a lonely drug addict with virtually no goals, no aspirations, no friends, and no family to a productive member of society. When I was using drugs, I honestly didn’t think I would make it past the age of 21. Now, I am 28, working a dream job sharing my experience to inspire others, and constantly growing. Nine years ago I was a hopeless, miserable human being. Now, I consider myself an inspiration to others who are struggling with addiction.

Q : What are the main benefits that emerged for you from getting sober?

Benny : There are so many benefits of being sober. The most important one is the fact that no matter what happens, I am experiencing everything with a clear mind. I live every day to the fullest and understand that every day I am sober is a miracle. The benefits of sobriety are endless. People respect me today and can count on me today. I grew up in sobriety and learned a level of maturity that I would have never experienced while using. I don’t have to rely on anyone or anything to make me happy. One of the greatest benefits from sobriety is that I no longer live in fear.

Case Study: Lorrie

Figure 1. Lorrie.

Lorrie Wiley grew up in a neighborhood on the west side of Baltimore, surrounded by family and friends struggling with drug issues. She started using marijuana and “popping pills” at the age of 13, and within the following decade, someone introduced her to cocaine and heroin. She lived with family and occasional boyfriends, and as she puts it, “I had no real home or belongings of my own.”

Before the age of 30, she was trying to survive as a heroin addict. She roamed from job to job, using whatever money she made to buy drugs. She occasionally tried support groups, but they did not work for her. By the time she was in her mid-forties, she was severely depressed and felt trapped and hopeless. “I was really tired.” About that time, she fell in love with a man who also struggled with drugs.

They both knew they needed help, but weren’t sure what to do. Her boyfriend was a military veteran so he courageously sought help with the VA. It was a stroke of luck that then connected Lorrie to friends who showed her an ad in the city paper, highlighting a research study at the National Institute of Drug Abuse (NIDA), part of the National Institutes of Health (NIH.) Lorrie made the call, visited the treatment intake center adjacent to the Johns Hopkins Bayview Medical Center, and qualified for the study.

“On the first day, they gave me some medication. I went home and did what addicts do—I tried to find a bag of heroin. I took it, but felt no effect.” The medication had stopped her from feeling it. “I thought—well that was a waste of money.” Lorrie says she has never taken another drug since. Drug treatment, of course is not quite that simple, but for Lorrie, the medication helped her resist drugs during a nine-month treatment cycle that included weekly counseling as well as small cash incentives for clean urine samples.

To help with heroin cravings, every day Lorrie was given the medication buprenorphine in addition to a new drug. The experimental part of the study was to test if a medication called clonidine, sometimes prescribed to help withdrawal symptoms, would also help prevent stress-induced relapse. Half of the patients received daily buprenorphine plus daily clonidine, and half received daily buprenorphine plus a daily placebo. To this day, Lorrie does not know which one she received, but she is deeply grateful that her involvement in the study worked for her.

The study results? Clonidine worked as the NIDA investigators had hoped.

“Before I was clean, I was so uncertain of myself and I was always depressed about things. Now I am confident in life, I speak my opinion, and I am productive. I cry tears of joy, not tears of sadness,” she says. Lorrie is now eight years drug free. And her boyfriend? His treatment at the VA was also effective, and they are now married. “I now feel joy at little things, like spending time with my husband or my niece, or I look around and see that I have my own apartment, my own car, even my own pots and pans. Sounds silly, but I never thought that would be possible. I feel so happy and so blessed, thanks to the wonderful research team at NIDA.”

• Liquor store. Authored by : Fletcher6. Located at : https://commons.wikimedia.org/wiki/File:The_Bunghole_Liquor_Store.jpg . License : CC BY-SA: Attribution-ShareAlike
• Benny Story. Provided by : Living Sober. Located at : https://livingsober.org.nz/sober-story-benny/ . License : CC BY: Attribution
• One patientu2019s story: NIDA clinical trials bring a new life to a woman struggling with opioid addiction. Provided by : NIH. Located at : https://www.drugabuse.gov/drug-topics/treatment/one-patients-story-nida-clinical-trials-bring-new-life-to-woman-struggling-opioid-addiction . License : Public Domain: No Known Copyright

Case Formulation and Intervention: Application of the Five Ps Framework in Substance Use Counseling

Volume 10 - Issue 3

Scott W. Peters

Substance use and misuse is exceedingly common and has numerous implications, both individual and societal, impacting millions of Americans directly and indirectly every year. Currently, there are a variety of empirically based interventions for treating clients who engage in substance use and misuse. The Five Ps is an idiographically based framework providing clinicians with a systematic and flexible means of addressing substance use and misuse that can be used in conjunction with standard substance use and misuse interventions. Additionally, its holistic and creative style provides opportunities to address concerns at various points with a variety of strategies and interventions that will best suit clients’ unique situations. It can assist both novice and experienced clinicians working with clients who present for counseling with substance use and misuse. Following a discussion of the Five Ps, a brief case illustration will demonstrate the framework.

Keywords : substance use and misuse, Five Ps, idiographic, systematic, flexible

Substance use and misuse in the United States is extremely common. For the year 2016, the Centers for Disease Control and Prevention (CDC) found that 18% of the U.S. population aged 12 and older had used illicit substances or misused prescription medications (CDC, 2018). The National Survey on Drug Use and Health asserted that close to 30% of respondents aged 12 and older reported use of illicit substances in the past month (Substance Abuse and Mental Health Services Administration [SAMHSA], 2017). Although these statistics are significant, it should be noted that “Most people who use abusable drugs, even most people who use them nonmedically, do so in a reasonably controlled fashion and without much harm to themselves or anyone else” (Kleiman et al., 2011, p. 2). In the context of this article, the word abusable indicates substances that when taken are pleasurable enough to result in excessive dosing or increased frequency of intake (Linden, 2011).

However, there are others who use substances to such an extent that it causes significant distress and impairment in their lives, a phenomenon clinically referred to as a substance use disorder (SUD). The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) bases an SUD on a “pathological pattern related to the use of a substance” (American Psychiatric Association, 2013, p. 483). In his report on alcohol, drugs, and health, the U.S. Surgeon General Vivek Murthy reported that more than 20 million Americans have an SUD (U.S. Department of Health and Human Services, 2016). Clients who engage in substance use and misuse can present with a variety of issues beyond use (Bahorik et al., 2017; Compton et al., 2014; Poorolajal et al., 2016). Thus, there exists a need to concurrently examine and address the potentially complex nature of client substance use and misuse.

Implications of Substance Use and Misuse

Substance use and misuse carries numerous potential repercussions. Societally, substance use and misuse consequences exceed “$400 billion in crime, health, and lost productivity” (U.S. Department of Health and Human Services, 2016, p. 2). Published data on those incarcerated appears to be several years old. However, it does suggest that more than 60% had a substance use disorder and 20% were under the influence at the time of their offense (National Center on Addiction and Substance Abuse at Columbia University, 2010). Regrettably, most do not receive treatment while incarcerated (Belenko et al., 2013). Additionally, many individuals who engage in substance use and misuse have co-occurring major medical conditions, such as cancers, cardiovascular accidents (strokes), and respiratory and cardiac illnesses (Bahorik et al., 2017). This population often experiences stigma and suboptimal health care results (McNeely et al., 2018; van Boekel et al., 2013). Substance use and misuse has significant impact on the occupational sector as well. Substance use and misuse has been correlated with both higher rates of absenteeism and workplace injuries (Bush & Lipari 2015). Those who engage in substance use and misuse often have higher rates of unemployment (Compton et al., 2014; Dieter, 2011). This can result in lack of access to treatment services, contributing to increased stress.

Substance use and misuse also has a negative impact on intimate partners, such as assuming increased responsibility and navigating unpredictability (Hussaarts et al., 2012). More ominously, substance use and misuse has been correlated with intimate partner violence (Murphy & Ting, 2010). Further, substance use and misuse is a significant risk factor for suicidality (Poorolajal et al., 2016). Finally, the number of U.S. adults with a comorbid SUD and mental illness has been shown to be almost 8 million, with only about 5% receiving treatment for both (SAMHSA, 2017). Concurrently treating both is very complex, challenging, and expensive. This can be even more problematic given the lack of health care access for large numbers of Americans (Schoen, 2013).

A Holistic Alternative

Addressing client substance use and misuse can be quite complicated, and as mentioned previously, substance use and misuse impacts users and society in a variety of ways beyond substance intake. There are several approaches to managing client substance use and misuse that have demonstrated effectiveness. Among those are 12-step programs (Humphreys et al., 2004), mindfulness-based interventions (Chiesa & Serretti, 2014), evidence-based approaches such as cognitive behavioral therapy (McHugh et al., 2010), and family counseling (O’Farrell & Clements, 2012). These approaches can be accomplished via outpatient counseling, partial hospitalization programs, inpatient and medically managed substance treatment programs, as well as residential and therapeutic communities. However, each has some shortcomings. Twelve-step attendance is most beneficial with inpatient substance use and misuse treatment (Karriker-Jaffe et al., 2018). Evidence-based approaches, such as cognitive behavioral therapy, tend to be nomothetic, assuming homogeneity and generally geared toward symptom amelioration (Robinson, 2011). Mindfulness-based strategies are not as effective when used alone as when used with other approaches (Sancho et al., 2018). Research on the success of family-based interventions has methodological challenges, such as small sample sizes and the difficulty of examining long-term outcomes (Rowe, 2012).

In addition, using these approaches may result in omitting the uniqueness of clients as a consideration in treatment. SAMHSA (2020) pointed out the significance of addressing clients individually based on their distinctive needs in order to provide the best chance for recovery from substance use and misuse. SAMHSA’s recommendations fit well with a more holistic framework in that such a structure allows clinicians to develop a multidimensional picture of clients. By examining and exploring clients’ use or misuse within the context of a multidimensional framework, interventions can be personalized, and areas of concern can be targeted. Such a framework may enhance the effectiveness of the aforementioned interventions (Wormer & Davis, 2018). Some of these evidence-based approaches will be demonstrated later in a case illustration.

As shown above, there are numerous ways to examine and treat client substance use and misuse. For example, some interventions use an individual lens, such as cognitive behavioral therapy, which examines connections between thoughts, feelings, and behaviors (Morin et al., 2017). Other approaches observe substance use and misuse from a family or systems perspective, looking at familial patterns such as communication and normalization of substance use (Bacon, 2019). Delivery of mindfulness-based interventions may help to address stressful events that previously triggered substance use (Garland et al., 2014). In addition, there are frameworks that use a formulation model examining various aspects of clients (Johnstone & Dallos, 2013) such as causal, contributing, environmental, and personal features, providing a much more expansive view of clients’ concerns.

Client substance use and misuse can be quite challenging for counselors, both novice and experienced. Case formulation, also referred to as conceptualization, is a skill new counselors often lack (Liese & Esterline, 2015). Using a framework to assist in case formulation may prove useful to beginning counselors. Experienced counselors, even with competence in a variety of approaches, can also benefit from using a framework to help address anticipated challenges (Macneil et al., 2012). Case formulations have been used in a number of areas such as those with psychosis, anxiety, and trauma (Chadwick et al., 2003; Ingram, 2012; Persons et al., 2013). One such framework is the Five Ps (Macneil et al., 2012). Macneil and his colleagues (2012) posited that diagnosing was insufficient and it was critical to include other factors such as causal, lifestyle, and personal factors in conceptualizing the case and formulating a plan. Applying this approach with clients who engage in substance use and misuse would allow more individual and flexible ways to intervene with client substance use and misuse. In addition, the collaborative nature of the Five Ps reinforces the concept of an idiographic formulation. This is in keeping with the inherent uniqueness of clients, their concerns, and a variety of factors.

The Five Ps is a type of framework utilizing five factors developed by Macneil et al. (2012). They conceptualized a way to look at clients and their problems, systematically and holistically taking into consideration the (1) Presenting problem, (2) Predisposing factors, (3) Precipitating factors, (4) Perpetuating factors, and (5) Protective factors. Presenting problems are concerns that clients find difficult to manage. Predisposing factors include biological, environmental, or personality considerations that may put clients at risk of further substance use and misuse. Precipitating factors are those that proximally bring about substance use and misuse and its resulting difficulties. Perpetuating factors are those that sustain and possibly reinforce clients’ current substance use and misuse challenges. Protective factors are those that help to moderate actual or potential substance use and misuse impact. The Five Ps framework promotes a very clear and systematic approach to case formulation or assessment that potentially provides a wealth of data. It also provides opportunities for a variety of interventions and strategies targeted to clients and their substance use and misuse or contributing factors.

Given the variations of substances, the level of use, the functional impairment, co-occurrence with other mental disorders, and inherent client differences, an idiographically based framework seems particularly appropriate with this population. The Five Ps permits counselors to both assess and intervene essentially simultaneously. It allows for client individualization, use of a variety of strategies, ongoing assessment, and modifications as needed. Furthermore, the Five Ps helps clients and counselors explore relationships between each factor and the presenting problem. This framework is idiographic in nature, as it looks at clients individually and holistically (Marquis & Holden, 2008). Idiographic case formulation can be useful for complicated cases, such as those encountered with clients engaged in substance use and misuse (Haynes et al., 1997). It is systematic, while allowing for flexibility and creativity. It can be used in outpatient, inpatient, and residential settings and possibly as part of an aftercare program.

Following is a case illustration demonstrating how the Five Ps may be helpful in formulating and engaging in a clinical application. It should be noted that several evidence-based substance use and misuse approaches were integrated in an eclectic approach throughout the case example to demonstrate the idiographic nature of the Five Ps. Many formulation models are administered within a cognitive behavioral grounding (Chadwick et al., 2003; Easden & Kazantzis, 2018; Persons et al., 2013). The Five Ps does not adhere to any particular theoretical orientation, thus allowing for a greater repertoire of strategies to draw from to help clients with substance use and misuse.

Implementing the Five Ps: The Case of Dax

A brief description of Dax, a hypothetical client, and the events that prompted him to seek services is followed by a detailed application of the Five Ps in addressing Dax’s substance use and misuse. It should be noted that the strategies and interventions applied here are used as illustrations and are specific to Dax and his concerns. In addition, the interventions demonstrated are not to be assumed the only ones that can be applied to Dax. They are examples that the author chose to illustrate the Five Ps in practice.

Dax is a 33-year-old married father of two children: a 9-year-old son, Cam, and a 7-year-old daughter, Zoe. He was recently driving home from work in the evening and law enforcement stopped him because of erratic driving. The officers evaluated him, detained him, and subsequently arrested him for driving while intoxicated. As part of his adjudication, Dax was required to attend five counseling sessions and have a clinician’s report provided to the court. Dax presents as extremely frustrated and embarrassed at being mandated to attend counseling sessions. He is confident that he does not have a problem and that counseling should be reserved for those who cannot stop drinking. Dax drinks two to three times a week, usually having one or two shots of whiskey and two to three draft beers. The night he was pulled over, he had had two additional beers and one additional shot of whiskey on top of his usual consumption after a telephone argument with his wife, Sara. Additionally, he reports significant stress and conflict in his marriage as well as concerns over some upcoming diagnostic tests for their daughter related to a heart murmur. Dax denies any other negative consequences from his alcohol use. He denies any significant increase in alcohol use or any other substance use. Presenting Problem While being mandated to attend counseling, Dax shares concerns that he is afraid of what his daughter’s test results will show. He fears that she will need open-heart surgery and that she may die. The clinician can intervene here by simply normalizing and validating his fears about the test results. A logical analysis using gentle Socratic dialogue may help to challenge his emotional reactions to his daughter’s heart murmur (Etoom & Ratnapalan, 2014). In addition, mindfulness strategies can assist in helping Dax to cognitively diffuse from present to future events (Harris, 2019). He is also adamant that he does not have a problem with alcohol. Here, a conversation about what counseling entails as well as psychoeducation related to the effects of alcohol on executive functioning may prove beneficial (Day et al., 2015). Acknowledging that his reticence is due to being obligated to attend counseling may assist in relationship building (Tahan & Sminkey, 2012). The clinician may also seek more information on the cause of the reported stress between him and his wife.

Predisposing Factors Dax reports a strong paternal history of substance use and misuse. His father started out drinking occasionally and over the years slowly developed a dependency on alcohol. Dax further reports his paternal grandfather died from liver failure. Addressing the potential genetic link to substance use and misuse may prove beneficial in raising Dax’s awareness (Dick & Agrawal, 2008). For example, the clinician may ask Dax if they can share how genes are passed on and expressed, like genes for eye color or hypertension. This may open the door to a conversation regarding how his substance use and misuse may progress to alcohol use disorder and its definition as a pattern of alcohol use leading to clinically significant problems, including increase in use, failed attempts to stop, and use leading to an impaired ability to meet role obligations (American Psychiatric Association, 2013). There could be a discussion of alcohol use disorder being a disease, not that different from any other passed-on trait or disease. Additionally, Dax often struggles with strong and painful emotions, and alcohol helps to address them. Here the clinician may utilize strategies drawn from acceptance and commitment therapy related to his control strategy of using alcohol to avoid his emotions (Harris, 2019). The ball in the pool metaphor (i.e., holding a beach ball under the water works temporarily, but eventually it pops back up) can be compared to alcohol temporarily holding those painful emotions down, eventually to resurface. The clinician may also discuss strategies to help Dax regulate his reactions using emotion-focused interventions such as positive reframing to ameliorate the stress of his daughter’s cardiac condition (Plate & Aldao, 2017).

Precipitating Factors This area explores significant occurrences that preceded or triggered the presenting problem and its consequences. Dax shares that he and his wife are conflicted about how to proceed with their daughter’s medical care. Sara is unequivocal in her confidence in Zoe’s cardiologist and his competence. Dax, however, is hyper-focused on surgery and seems to dismiss Sara’s position. At the end of his workday, he and his wife got into an argument over the phone about an upcoming diagnostic test and the possible results. Dax was quite upset, cursed at her, and then hung up the phone. He then stopped at a local pub and had several drinks.

Here, the clinician may use reality-based strategies that address choice and consequences (Wubbolding & Brickell, 2017). This may include a direct conversation about Dax’s decision to drink, resulting in his becoming impaired, with the consequence of being detained, charged, and adjudicated. Dax can then share his and his wife’s perspectives on their daughter’s care. This conversation can lead to investigating strategies for how each can be heard, including short role-plays with opportunities to practice (Worrell, 2015). The clinician can provide a variety of potential spousal responses, allowing for more adaptability and flexibility in Dax’s responses. The goal here is to build Dax’s competence in communicating, both in listening and expressing. Additionally, there may be a discussion using aspects of existentialism to process inherent anxiety and its connection to unknowable future events (May, 1950; Wu et al., 2015).

Perpetuating Factors The emphasis here is on features that continue the presenting problem. For Dax, he shares that when he and his wife argue, it follows a very predictable pattern. They disagree, interrupt one another, yell, and he calms down by having several beers. He then withdraws and becomes sullen for a few days. Nothing gets resolved, and this cycle appears once again when they have conflict.

The clinician may discuss the concept of circularity and assist in moving from “vicious cycles” to “virtuous cycles and problem resolution” (Walsh, 2014, p. 162). This involves explaining that interactions can act as a kind of back-and-forth loop of action–reaction–action without any resolution, leaving both parties feeling unheard, misunderstood, and frustrated. The goals here are to both break the pattern and to facilitate healthy conversations. Here the clinician may incorporate a solution-focused strategy exploring a time with Dax when he and his wife have disagreed, but he did not interrupt and the outcome was positive (de Shazer, 1985). If he cannot identify a time, simple role-plays in which Dax does not interrupt or yell and instead experiences different outcomes may provide optimism to Dax. The counselor may also assist Dax in emotional regulation, which may prevent the initiation of arguments (Aldao & Nolen-Hoeksema, 2013). In addition, aspects of narrative therapy may provide an opportunity for Dax to re-author a unique outcome that gives meaning and provides a functional identity to him as a father and husband, thus building a sense of optimism (White & Epston, 1990).

Protective Factors Here the focus is on investigating resources and/or supports that may help prevent client substance use and misuse from further becoming problematic. This factor has generally been underutilized despite being shown as beneficial to clients (Kuyken et al., 2009). This is often the opportunity for the client to share what may help them move forward, what their assets are, who can support them, and any other self-identified skills (de Shazer, 1985). These can be in the form of personal characteristics such as tenacity, intellect, or insight. They may also present in the form of family, friends, or hobbies. Oftentimes, when the topic of protective factors is used in substance use and misuse, it is related to deterrence of substance use, notably with adolescents (Liao et al., 2018). In the Five Ps context, protective factors are used to potentially prevent substance use and misuse from having more negative impact as well as to increase client resilience. This factor differs markedly from the first four. Protective factors move away from the problem areas that need interventions to hope and optimism and look to future success and competence (Macneil et al., 2012). Once the protective factors are identified, the ensuing conversation provides opportunities to imagine future outcomes in which protective factors may come into play should situations occur that the client finds problematic. Second, it also tends to shift the conversation toward what is present and going well in their lives and away from those areas that cause distress and suffering (de Shazer, 1985).

In implementing the Five Ps framework with Dax, the clinician chose to use psychoeducation and strategies borrowed from acceptance and commitment, reality, Bowenian family systems, and solution-focused brief therapies to assist Dax with his substance use and misuse. The choice of the above approaches is only meant as an illustration and not as definitive ways to address this particular client. It is likely that other clinicians presented with Dax would use a different combination of approaches. The Five Ps is a systematic way to look at clients and their presentation, and its idiographic construction takes clients’ uniqueness into account. It also allows clinicians to target specific areas of concern (Macneil et al., 2012) and may be used in a variety of clinical settings. Moreover, the Five Ps align with SAMHSA’s recommendation that clinicians tailor treatment to each client because no single treatment is particularly superior (SAMHSA, 2020).

Limitations and Future Research

There are limitations to the Five Ps framework as a way to formulate and intervene with clients’ substance use and misuse. First and foremost, it should be emphasized that this particular framework has not been empirically tested with client substance use and misuse. However, as mentioned previously, case formulations have been used across a variety of client concerns (Chadwick et al., 2003; Ingram, 2012; Persons et al., 2013). Another potential limitation is that the Five Ps may not be particularly beneficial for substance use and misuse in which there is clinical evidence of an SUD that includes significant withdrawal symptoms. Client substance use and misuse at that level may need medical stabilization and detoxification prior to utilization of the Five Ps. In addition, there may be clients who are simply not ready or able to address some or most of the dimensions of the Five Ps. Furthermore, clients like Dax who are mandated to attend substance-related counseling may have service plans that are not congruent with the Five Ps framework. In spite of these limitations, there may be several potential areas of inquiry.

Previous studies using frameworks to formulate have often used cognitive behavioral therapy as the primary intervention (Chadwick et al., 2003; Persons et al., 2013). Given that client substance use and misuse can be quite complicated, using various approaches within the Five Ps framework may yield positive results. As Chadwick et al. (2003) noted, examining positive client experiences may be one way to discover how to increase client participation in substance use and misuse treatment. Another potential area of study might involve comparing novice counselors to more experienced counselors. As mentioned previously, novice counselors often lack sufficient case formulation skills (Liese & Esterline, 2015). Examining the two groups’ experiences using the Five Ps may provide insight to assist counselor training programs related to substance use and misuse skill development. The implementation of the Five Ps with clients with mild substance use and misuse and those with more significant substance use and misuse, possibly using the DSM-5 diagnosis for SUD, may be another area to explore. This research could point to populations for whom the Five Ps is more and less effective. Studies utilizing the Five Ps with mandated clients may demonstrate its efficacy, notably with agencies that require substance-related counseling.

Client substance use and misuse is a significant problem in the United States, and it continues to cause difficulty for individuals, families, and society. There are numerous methods and combinations of methods to address substance use and misuse, such as family therapy, cognitive behavioral therapy, and self-help groups. Their effectiveness has been well researched, and this paper does not propose a superior way to address substance use and misuse. However, the Five Ps presents a framework in which counselors can examine and intervene with client substance use and misuse using a variety of approaches and strategies. The Five Ps can be used in a variety of settings such as a community mental health agency, primary care clinic, and inpatient or residential treatment centers. The systematic but flexible nature of this framework affords clinicians numerous ways to address substance use and misuse. For some, receiving substance use and misuse services can be stigmatizing. In fact, this stigmatization can come from those who are treating them (Luoma et al., 2007). In addition, the vast majority of those with an SUD never receive treatment (Han et al., 2015). Incorporating the Five Ps, with its holistic framework, may prove attractive to clients and counselors, thus potentially increasing the numbers of clients engaged in substance use and misuse treatment. As mentioned previously, the Five Ps is not meant to replace any other substance use and misuse intervention. It is another way to address the multifaceted and complicated nature of client substance use and misuse. Novice clinicians, who often have a more limited repertoire of strategies, may find the Five Ps valuable because of its systematic framework to clients. Experienced clinicians understandably have a larger catalogue of strategies to choose from. However, they may find this framework valuable as it provides one more way to address the often-encountered complex challenges of substance use and misuse.

Conflict of Interest and Funding Disclosure The authors reported no conflict of interest or funding contributions for the development of this manuscript.

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Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: Systematic review. Drug and Alcohol Dependence, 131(1–2), 23–35. https//doi.org/10.1016/j.drugalcdep.2013.02.018 Van Wormer, K., & Davis, D. R. (2018). Addiction treatment: A strengths perspective (4th ed.). Cengage. Walsh, F. (2014). Family therapy: Systemic approaches to practice. In J. R. Brandell (Ed.), Essentials of clinical social work (pp. 160–185). SAGE. White, M., & Epston, D. (1990). Narrative therapy to therapeutic ends. W. W. Norton. Worrell, M. (2015). Cognitive behavioural couple therapy. Routledge. Wu, J. Q., Szpunar, K. K., Godovich, S. A., Schacter, D. L., & Hofmann, S. G. (2015). Episodic future thinking in generalized anxiety disorder. Journal of Anxiety Disorders, 36, 1–8. https://doi.org/10.1016/j.janxdis.2015.09.005 Wubbolding, R. E., & Brickell, J. (2017). Counselling with reality therapy (2nd ed.). Routledge.

Scott W. Peters, PhD, LPC-S, is an associate professor at Texas A&M University – San Antonio. Correspondence may be addressed to Scott Peters, One University Way, San Antonio, TX 78224, [email protected].

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Robert’s story

Robert was living with an alcohol addiction and was homeless for over 25 years. He was well known in the local community and was identified as one of the top 100 A&E attendees at the Local General Hospital.

He drank all day every day until he would pass out and this was either in the town centre or just by the roadside. In addition, Robert was also incontinent and really struggled with any meaningful communication or positive decision making due to his alcohol usage. This often resulted in local services such as police, ambulance being called in to help. He had no independent living skills and was unable to function without alcohol.

In addition, and due to his lifestyle and presenting behaviours, Robert had a hostile relationship with his family and had become estranged from them for a long period of time.

Robert needed ongoing support and it was identified at the General Hospital that if he was to carry on “living” the way he currently was, then he wouldn’t survive another winter.

On the back of this, Robert was referred to Calico who organised a multi-disciplinary support package for him, which included support with housing as part of the Making Every Adult Matter programme.

After some initial challenges, Robert soon started to make some positive changes.

The intensive, multidisciplinary support package taught him new skills to support him to live independently, sustain his tenancy and make some positive lifestyle changes which in turn would improve his health and wellbeing.

This included providing daily visits in the morning to see Robert and to support him with some basic activities on a daily/weekly basis. This included getting up and dressed; support with shopping and taking to appointments; guidance to help make positive decisions around his associates; support about his benefits and managing his money. In addition, he was given critical support via accessing local groups such as RAMP (reduction and motivational programme) and Acorn (drugs and alcohol service), as well as 1 to 1 sessions with drugs workers and counsellors to address his alcohol addiction.

After six months Robert continued to do well and was leading a more positive lifestyle where he had greatly reduced his A&E attendance. He had significantly reduced his alcohol intake with long periods of abstinence and was now able to communicate and make positive decisions around his lifestyle.

Critically he had maintained his tenancy and continued to regularly attend local groups and other support for his alcohol addiction and had reconnected with some of his family members.

By being able to access these community resources and reduce his isolation he is now engaged in meaningful activities throughout the day and has been able to address some of his critical issues. A small but significant example is that Robert is now wearing his hearing aids which means that he can now interact and communicate more effectively.

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Jo-Hanna Ivers 1* and Kevin Ducray 2

In October 2012, 83 front-line Irish service providers working in the addiction treatment field received accreditation as trained practitioners in the delivery of a number of evidence-based positive reinforcement approaches that address substance use: 52 received accreditation in the Community Reinforcement Approach (CRA), 19 in the Adolescent Community Reinforcement Approach (ACRA) and 12 in Community Reinforcement and Family Training (CRAFT). This case study presents the treatment of a 17-year-old white male engaging in high-risk substance use. He presented for treatment as part of a court order. Treatment of the substance use involved 20 treatment sessions and was conducted per Adolescent Community Reinforcement Approach (A-CRA). This was a pilot of A-CRA a promising treatment approach adapted from the United States that had never been tried in an Irish context. A post-treatment assessment at 12-week follow-up revealed significant improvements. At both assessment and following treatment, clinician severity ratings on the Maudsley Addiction Profile (MAP) and the Alcohol Smoking and Substance Involvement Screening Test (ASSIST) found decreased score for substance use was the most clinically relevant and suggests that he had made significant changes. Also his MAP scores for parental conflict and drug dealing suggest that he had made significant changes in the relevant domains of personal and social functioning as well as in diminished engagement in criminal behaviour. Results from this case study were quite promising and suggested that A-CRA was culturally sensitive and applicable in an Irish context.

1. Theoretical and Research Basis for Treatment

Substance use disorders (SUDs) are distinct conditions characterized by recurrent maladaptive use of psychoactive substances associated with significant distress. These disorders are highly common with lifetime rates of substance use or dependence estimated at over 30% for alcohol and over 10% for other substances [1 , 2] . Changing substance use patterns and evolving psychosocial and pharmacologic treatments modalities have necessitated the need to substantiate both the efficacy and cost effectiveness of these interventions.

Evidence for the clinical application of cognitive behavioural therapy (CBT) for substance use disorders has grown significantly [3 - 8] . Moreover, CBT for substance use disorders has demonstrated efficacy both as a monotherapy and as part of combination treatment [7] . CBT is a time-limited, problem-focused, intervention that seeks to reduce emotional distress through the modification of maladaptive beliefs, assumptions, attitudes, and behaviours [9] . The underlying assumption of CBT is that learning processes play an imperative function in the development and maintenance of substance misuse. These same learning processes can be used to help patients modify and reduce their drug use [3] .

Drug misuse is viewed by CBT practitioners as learned behaviours acquired through experience [10] . If an individual uses alcohol or a substance to elicit (positively or negatively reinforced) desired states (e.g. euphorigenic, soothing, calming, tension reducing) on a recurrent basis, it may become the preferred way of achieving those effects, particularly in the absence of alternative ways of attaining those desired results. A primary task of treatment for problem substance users is to (1) identify the specific needs that alcohol and substances are being used to meet and (2) develop and reinforce skills that provide alternative ways of meeting those needs [10 , 11] .

CRA is a broad-spectrum cognitive behavioural programme for treating substance use and related problems by identifying the specific needs that alcohol and or other substances are satisfying or meeting. The goal is then to develop and reinforce skills that provide alternative ways of meeting those needs. Consistent with traditional CBT, CRA through exploration, allows the patient to identify negative thoughts, behaviours and beliefs that maintain addiction. By getting the patient to identify, positive non-drug using behaviours, interests, and activities, CRA attempts to provide alternatives to drug use. As therapy progresses the objective is to prevent relapse, increase wellness, and develop skills to promote and sustain well-being. The ultimate aim of CRA, as with CBT is to assist the patient to master a specific set of skills necessary to achieve their goals. Treatment is not complete until those skills are mastered and a reasonable degree of progress has been made toward attaining identified therapy goals. CRA sessions are highly collaborative, requiring the patient to engage in ‘between session tasks’ or homework designed reinforce learning, improve coping skills and enhance self efficacy in relevant domains.

The use of the Community Reinforcement Approach is empirically supported with inpatients [12 , 13] , outpatients [14 - 16] and homeless populations (Smith et al., 1998). In addition, three recent metaanalytic reviews cited CRA as one of the most cost-effective treatment programmes currently available [17 , 18] .

A-CRA is a evidenced based behavioural intervention that is an adapted version of the adult CRA programme [19] . Garner et al [19] modified several of the CRA procedures and accompanying treatment resources to make them more developmentally appropriate for adolescents. The main distinguishing aspect of A-CRA is that it involves caregivers—namely parents or guardians who are ultimately responsible for the adolescent and with whom the adolescent is living.

A-CRA has been tested and found effective in the context of outpatient continuing care following residential treatment [20 - 22] and without the caregiver components as an intervention for drug using, homeless adolescents [23] . More recently, Garner et al [19] collected data from 399 adolescents who participated in one of four randomly controlled trials of the A-CRA intervention, the purpose of which was to examine the extent to which exposure to A-CRA procedures mediated the relationship between treatment retention and outcomes. The authors found adolescents who were exposed to 12 or more A-CRA procedures were significantly more likely to be in recovery at follow-up.

Combining A-CRA with relapse prevention strategies receives strong support as an evidence based, best practice model and is widely employed in addiction treatment programmes. Providing a CBT-ACRA therapeutic approach is imperative as it develops alternative ways of meeting needs and thus altering dependence.

2. Case Introduction

Alan is a 17 year-old male currently living in County Dublin. Alan presented to the agency involuntarily and as a requisite of his Juvenile Liaison Officer who was seeing him on foot of prior drugs arrest for ‘possession with intent to supply’; a more serious charge than a simple ‘drugs possession’ charge. As Alan had no previous charges he was placed on probation for one year. This was Alan’s first contact with the treatment services. A diagnostic assessment was completed upon entry to treatment and included completion of a battery of instruments comprising the Maudsley Addiction Profile (MAP), The World Health Organization Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and the Beck Youth Inventory (BYI) (see appendices for full description of outcome measures) (Table 1).

3. Diagnostic Criteria

The apparent symptoms of substance dependency were: (1) Loss of Control - Alan had made several attempts at controlling the amounts of cannabis he consumed, but those times when he was able to abstain from cannabis use were when he substituted alcohol and/or other drugs. (2) Family History of Alcohol/Drug Usage - Alan’s eldest sister who is now 23 years old is in recovery from opiate abuse. She was a chronic heroin user during her early adult years [17 - 21] . During this period, which corresponds to Alan’s early adolescent years [12 - 15] she lived in the family home (3) Changes in Tolerance - Alan began per day. At presentation he was smoking six to eight cannabis joints daily through the week, and eight to twelve joints daily on weekends.

4. Psychosocial, Medical and Family History

At time of intake Alan was living with both of his parents and a sister, two years his senior, in the family home. Alan was the youngest and the only boy in his family. He had two other older sisters, 5 and 7 years his senior. He was enrolled in his 5th year of secondary school but at the time of assessment was expelled from all classes. Alan had superior sporting abilities. He played for the junior team of a first division football team and had the prospect of a professional career in football. He reported a family history positive for substance use disorders. An older sister was in recovery for opiate dependence. Apart from his substance use Alan reported no significant psychological difficulties or medical problems. His motives for substance use were cited as boredom, curiosity, peer pressure, and pleasure seeking. His triggers for use were relationship difficulties at home, boredom and peer pressure. Pre-morbid personality traits included thrill seeking and impulsivity (Table 2).

5. Case Conceptualisation

A CBT case formulation is based on the cognitive model, which hypothesizes that "a person’s feelings and emotions are influenced by their perception of events" . It is not the actual event that determines how the person feels, but rather how they construe the event (Beck, 1995 p14). Moreover, cognitive theory posits that the “child learns to construe reality through his or her early experiences with the environment, especially with significant others” and that “sometimes these early experiences lead children to accept attitudes and beliefs that will later prove maladaptive” [24] . A CBT formulation (or case conceptualisation) is one of the key underpinnings of Cognitive Behavioural Therapy (CBT). It is the ‘blueprint’ which aids the therapist to understand and explain the patient’s’ problems.

Formulation driven CBT enables the therapist to develop an individualised understanding of the patient and can help to predict the difficulties that a patient may encounter during therapy. In Alan’s case, exploring his existing negative automatic thoughts about regarding school and his academic competences highlighted the difficulties he could experience with CBT homework completion. Whilst Alan was good at between session therapy assignments, an exploration of what is meant by ‘homework’ in a CBT context was crucial.

A collaborative CBT formulation was done diagrammatically together with Alan (Figure 1). This formulation aimed to describe his presenting problems and using CBT theory, to explore explanatory inferences about the initiating and maintaining factors of his drug use which could practically inform meaningful interventions.

Simmons and Griffiths et al. make the insightful observation that particular group differences need to be specifically considered and suggest that the therapist should be cognizant of the role of both society and culture when developing a formulation. They firstly suggest that the impact played by gender, sexuality and socio-cultural roles in the genesis of a psychological disorder, namely the contribution that being a member of a group may have on predisposing and precipitating factors, be carefully considered. An example they offer is the role of poverty on the development of psychological problems, such as the link evidenced between socio economic group and onset of schizophrenia. This was clearly evident in the case of Alan, who being a member of a deprived socioeconomic group, growing up and living in an area with a high level of economic deprivation, perceived that his choices for success were limited. His thinking, as an adolescent boy, was dichotomous in that he saw himself as having only two fixed and limited choices (a) being good at sport he either pursue a career as a professional sportsman or alternatively (b) he engage in crime and work his way up through the ranks as a ‘career criminal’. Simmons & Griffiths secondly suggest that being a member of a particular group can heavily influence a person’s understanding of the causality of their psychological disorder. A third consideration when developing a formulation is the degree to which being a member of a particular group may influence the acceptance or rejection of a member experiencing a psychological illness. Again this is pertinent in Alan’s case as he was part of a sub-group, a gang engaged in crime. For this cohort, crime and drug use were synonymous. Using drugs was viewed as a rite of passage for Alan.

Drug use, according to CBT models, are socially learned behaviours initiated, maintained and altered through the dynamic interaction of triggers, cues, reinforcers, cognitions and environmental factors. The application of a such a formulation, sensitive to Simmons and Griffiths (2009) aforementioned observations, proved useful in affording insights into the contextual and maintaining factors of Alan’s drug use which was heavily influenced by the availability of drugs ,his peer group (with whom he spent long periods of time) and their petty drug dealing and criminality. Similarly, engaging with his football team mates during the lead up to an important match significantly reduced his drug use and at certain times of the year even lead to abstinence. Sharing this formulation allowed him to note how his drug use patterns were driven, as per the CBT paradigm, by modifiable external, transient, and specific factors (e.g. cues, reinforcements, social networks and related expectations and social pressures).

Employing the A-CRA model allowed for this tailored fit as A-CRA specifically encourages the patient to identify their own need and desire for change. Alan identified the specific needs that were met by using substances and he developed and reinforced skills that provided him with alternative ways of meeting those needs. This model worked extremely well for Alan as he had identified and had ready access to a pro- social ‘alternative group’ or community. As he had had access to an alternative positive peer group and another activity (sport) which he was ‘really good at’, he simply needed to see the evidence of how his context could radically affect his substance use; more specifically how his beliefs, thinking and actions in certain circumstances produced very different drug use consequences and outcomes.

6. Course of Treatment and Assessment of Progress

One focus of CBT treatment is on teaching and practising specific helpful behaviours, whilst trying to limit cognitive demands on clients. Repetition is central to the learning process in order to develop proficiency and to ensure that newly acquired behaviours will be available when needed. Therefore, behavioural using rehearsal will emphasize varied, realistic case examples to enhance generalization to real life settings. During practice periods and exercises, patients are asked to identify signals that indicate high-risk situations, demonstrating their understanding of when to use newly acquired coping skills. CBT is designed to remedy possible deficits in coping skills by better managing those identified antecedents to substance use. Individuals who rely primarily on substances to cope have little choice but to resort to substance use when the need to cope arises. Understanding, anticipating and avoiding high risk drug use scenarios or the “early warning signals” of imminent drug use is a key CBT clinical activity.

A major goal of a CBT/A-CRA therapeutic approach is to provide a range of basic alternative skills to cope with situations that might otherwise lead to substance use. As ‘skill deficits’ are viewed as fundamental to the drug use trajectory or relapse process, an emphasis is placed on the development and practice of coping skills. A-CRA was manualised in 2001 as part of the Cannabis Youth Treatment Series (CYT) and was tested in that study [21] and more recently with homeless youth [23] . It was also adapted for use in a manual for Assertive Continuing Care following residential treatment [20] .

There are twelve standard and three optional procedures proposed in the A-CRA model. The delivery of the intervention is flexible and based on individual adolescent needs, though the manual provides some general guidelines regarding the general order of procedures. Optional procedures are ‘Dealing with Failure to Attend’, ‘Job-Seeking Skills’, and ‘Anger Management’. Standard procedures are included in table 3 below. For a more detailed description of sessions and procedures please see appendices.

Smith and Myers describe the theoretical underpinnings of CRA as a comprehensive behavioural program for treating substance-abuse problems. It is based on the belief that environmental contingencies can play a powerful role in encouraging or discouraging drinking or drug use. Consequently, it utilizes social, recreational, familial, and vocational reinforcers to assist consumers in the recovery process. Its goal is to essentially make a sober lifestyle more rewarding than the use of substances. Interestingly the authors note: ‘Oddly enough, however, while virtually every review of alcohol and drug treatment outcome research lists CRA among approaches with the strongest scientific evidence of efficacy, very few clinicians who treat consumers with addictions are familiar with it’. ‘The overall philosophy is to promote community based rewarding of non drug-using behaviour so that the patient makes healthy lifestyle changes’ p.3 [25] .

A-CRA procedures use ‘operant techniques and skills training activities’ to educate patients and present alternative ways of dealing with challenges without substances. Traditionally, CRA is provided in an individual, context-specific approach that focuses on the interaction between individuals and those in their environments. A-CRA therapists teach adolescents when and where to use the techniques, given the reality of each individual’s social environment. This tailored approach is facilitated by conducting a ‘functional analysis’ of the adolescent’s behaviour at the beginning of therapy so they can better understand and interrupt the links in the behavioural chain typically leading to episodes of drug use. A-CRA therapists then teach individuals how to improve communication and other skills, build on their reinforcers for abstinence and use existing community resources that will support positive change and constructive support systems.

A-CRA emphasises lapse and relapse prevention. Relapseprevention cognitive behavioural therapy (RP-CBT) is derived from a cognitive model of drug misuse. The emphasis is on identifying and modifying irrational thoughts, managing negative mood and intervening after a lapse to prevent a full-blown relapse [26] . The emphasis is on development of skills to (a) recognize High Risk Situations (HRS) or states where clients are most vulnerable to drug use, (b) avoidance of HRS, and (C) to use a variety of cognitive and behavioural strategies to cope effectively with these situations. RPCBT differs from typical CBT in that the accent is on training people who misuse drugs to develop skills to identify and anticipate situations or states where they are most vulnerable to drug use and to use a range of cognitive and behavioural strategies to cope effectively with these situations [26] .

7. Access and Barriers to Care

Alan engaged with the service for eight months. During this time he received twenty sessions, three of which were assessment focused, the remaining seventeen sessions were A-CRA focused; two of the seventeen involved his mother, the remaining fifteen were individual. As Alan was referred by the probation services, he was initially somewhat ambivalent about drug use focussed interventions. His early motivation for engagement was primarily to avoid the possibility of a custodial sentence.

8. Treatment

My sessions with Alan were guided by the principles of A-CRA [27] which focuses on coping skills training and relapse prevention approaches to the treatment of addictive disorders. Prior to engaging with Alan, I had completed the training course and commenced the A-CRA accreditation process, both under the stewardship of Dr Bob Meyers, whose training and publication offers detailed guidelines on skills training and relapse prevention with young people in a similar context [27] .

During the early part of each session I focused on getting a clear understanding of Alan’s current concerns, his general level of functioning, his substance abuse and pattern of craving during the past week. His experiences with therapy homework, the primary focus being on what insight he gained by completing such exercises was also explored. I spent considerable time engaged in a detailed review of Alan’s experience with the implementation of homework tasks during which the following themes were reviewed:

-Gauging whether drug use cessation was easier or harder than he anticipated? -Which, if any, of the coping strategies worked best? -Which strategies did not work as well as expected. Did he develop any new strategies? -Conveying the importance of skills practice, emphasising how we both gained greater insights into how cognitions influenced his behaviour. After developing a clear sense of Alan’s general functioning, current concerns and progress with homework implementation, I initiated the session topic for that week. I linked the relevance of the session topic to Alan’s current cannabis-related concerns and introduced the topic by using concrete examples from Alan’s recent experience. While reviewing the material, I repeatedly ensured that Alan understood the topic by asking for concrete examples, while also eliciting Alan’s views on how he might use these particular skills in the future.

Godley & Meyers [21] propose a homework exercise to accompany each session. An advantage of using these homework sheets is that they also summarise key points about each topic and therefore serve as a useful reminder to the patient of the material discussed each week. Meyers, et al. (2011) suggests that rather than being bound by the suggested exercises in the manualised approach, they may be used as a starting point for discussing the best way to implement the required skill and to develop individualised variations for new assignments [27] . The final part of each session focused on Alan’s plan for the week ahead and any anticipated high-risk situations. I endeavoured to model the idea that patients can literally ‘plan themselves out of using’ cannabis or other drugs. For each anticipated high-risk situation, we identified appropriate and viable coping skills. Better understanding, anticipating and planning for high-risk situations was difficult in the beginning of treatment as Alan was not particularly used to planning or thinking through his activities. For a patient like Alan, whose home life is often chaotic, this helped promote a growing sense of self efficacy. Similarly, as Alan had been heavily involved with drug use for a long time, he discovered through this process that he had few meaningful activities to fill his time or serve as alternatives to drug use. This provided me with an opportunity to discuss strategies to rebuild an activity schedule and a social network.

During our sessions, several skill topics were covered. I carefully selected skills to match Alan’s needs. I selected coping skills that he has used in the past and introduced one or two more that were consistent with his cognitive style. Alan’s cognitive score indicated a cognitive approach reflecting poor problem solving or planning. Sessions focused on generic skills including interpersonal skills, goal setting, coping with criticism or anger, problem solving and planning. The goal was to teach Alan how to build on his pro- social reinforcers, how to use existing community resources supportive of positive change and how to develop a positive support system.

The sequence in which these topics were presented was based on (a) patient needs and (b) clinician judgment (a full description of individual sessions may be found in appendices).

A-CRA procedures use ‘operant techniques and skills training activities’ to educate patients and present alternative ways of dealing with challenges without substances. Traditionally, CRA is provided in an individual, context-specific approach that focuses on the interaction between individuals and those in their environments. A-CRA therapists teach adolescents when and where to use the techniques, given the reality of each individual’s social environment.

9. Assessment of Treatment Outcome

A baseline diagnostic assessment of outcomes was completed upon treatment entry. This assessment consisted of a battery of psychological instruments including (see appendices for full a description of assessment measures):

-The Maudsley Addiction Profile (MAP). -The Beck Youth Inventories. -The World Health Organization Alcohol, Smoking and Substance Involvement Screening Test (ASSIST).

In addition to the above, objective feedback on Alan’s clinical and drug use status through urine toxicology screens was an important part of his drug treatment. Urine specimens were collected before each session and available for the following session. The use of toxicology reports throughout treatment are considered a valuable clinical tool. This part of the session presents a good opportunity to review the results of the most recent urine toxicology screen and promote meaningful therapeutic activities in the context of the patient’s treatment goals [28] .

In reporting on substance use since the last session, patients are likely to reveal a great deal about their general level of functioning and the types of issues and problems of most current concern. This allows the clinician to gauge if the patient has made progress in reducing drug use, his current level of motivation, whether there is a reasonable level of support available in efforts to remain abstinent and what is currently bothering him. Functional analyses are opportunistically used throughout treatment as needed. For example, if cannabis use occurs, patients are encouraged to analyse antecedent events so as to determine how to avoid using in similar situations in the future. The purpose is to help the patient understand the trajectory and modifiable contextual factors associated with drug use, challenge unhelpful positive drug use expectancies, identify possible skills deficiencies as well as seeking functionally equivalent non- drug using behaviours so as to reduce the probability of future drug use. The approach I used is based on the work of [28] .

The Functional Analysis was used to identify a number of factors occurring within a relatively brief time frame that influenced the occurrence of problem behaviours. It was used as an initial screening tool as part of a comprehensive functional assessment or analysis of problem behaviour. The results of the functional analysis then served as a basis for conducting direct observations in a number of different contexts to attest to likely behavioural functions, clarify ambiguous functions, and identify other relevant factors that are maintaining the behaviour.

The Happiness Scale rates the adolescent’s feelings about several critical areas of life. It helps therapists and adolescents identify areas of life that adolescents feel happy about and alternatively areas in which they have problems or challenges. Most importantly it identifies potential treatment goals subjectively meaningful to the patient, facilitates positive behaviour change in a range of life domains as well as help clients track their progress during treatment.

Alan’s BYI score (Table 4) indicates that at the time of assessment he was within the average scoring range on ‘self-concept’, and moderately elevated in the areas of ‘depression’, ‘anxiety’, and ‘disruptive behaviour’. His score for ‘anger’ suggested that his anger fell within the extremely elevated range. When this was discussed with Alan he agreed that this was quite accurate. Anger, and in particular controlling his anger, was subjectively identified as a treatment goal.

10. Follow-up

Given that follow-up occurred by telephone it was not feasible to administer the full battery of tests. With Alan’s treatment goals in mind it was decided to administer the MAP and ASSIST. Table 5 below illustrates Alan’s score at baseline and follow-up for the MAP and ASSIST. For summary purposes I have taken areas for concern at baseline for both instruments.

Alan’s score for cannabis was the most clinically relevant as it placed him in the 'high risk’ domain while his alcohol score indicated that he had engaged in binge drinking (6+ drinks) at T1. However, at T2 Alan’s score suggests that he had made considerable reductions in the use of both substances. Also his MAP scores for parental conflict and drug dealing suggest that he had also made major positive changes in the relevant domains of personal and social functioning as well as ceasing criminal behaviour.

At 3 months post-discharge I contacted Alan by phone. He had maintained and continued to further his progress. His drug use was at a minimal level (1 or 2 shared joints per month). He was no longer engaged in crime and his probationary period with the judicial system had passed. He had received a caution for his earlier drugs charge. At the time of follow-up he was enjoying participating in a Sports Coaching course and was excelling with his study assignments. Relationships had improved considerably with his mother and sister and he had re-engaged with a previous, positive, peer group linked to his involvement with the GAA . Overall he felt he was doing extremely well.

11. Complicating Factors with A-CRA Model

There are many challenges that may arise in the treatment of substance use disorders that can serve as barriers to successful treatment. These include acute or chronic cognitive deficits, health problems, social stressors and a lack of social resources [7] . Among individuals presenting with substance use there are often other significant life challenges including early school leaving, family conflicts, legal issues, poor or deviant social networks, etc. A particular challenge with Alan’s case was the social and environmental milieu which he shared with his drug using peers. For Alan, who initially had few skills and resources, engaging in treatment meant not only being asked to change his overall way of life but also to renounce some of those components in which he enjoyed a sense of belonging, particularly as he had invested significantly in these friendships. A sense of ‘belonging to the substance use culture’ can increase ambivalence for change [7] . Alan’s mother strongly disapproved of his drug using peer group and failed to acknowledge Alan’s perceived loss. This resulted in mother- son conflict. The use of the caregiver session allowed an exploration of perceived ‘losses’ relative to the ‘gains’ associated with Alan’s abstinence. It was moreover seen to be critical to establish alternatives for achieving a sense of belonging, including both his social connection and his social effectiveness. Alan’s sports ability allowed for this to be fostered. He is a talented sportsman which often meant his acceptance within a team or group is a given.

Despite the positive effects of A-CRA it is not without its shortcomings. The approach is at times quite American- oriented, particularly around identifying local resources and its focus on culturally specific outlets in promoting social engagement as alternatives to substance use. While this is supported in the literature, it may not necessarily be transferable to certain Irish adolescent contexts or subcultures.

12. Treatment Implications of the Case

A-CRA captures a broad range of behavioural treatments including those targeting operant learning processes, motivational barriers to improvement and other more traditional elements of cognitivebehavioural interventions. Overall, this intervention has demonstrated efficacy. Despite this heterogeneity, core elements emerge based in a conceptual model of SUDs as disorders characterized by learning processes and driven by the strongly reinforcing effects of the substances of abuse. There is rich evidence in the substance use disorders literature that improvement achieved by CBT (7) and indeed A-CRA (Godley et al. and Garner et al. [22 , 20] ) generalizes to all areas of functioning, including social, work, family and marital adjustment domains. The present study’s finding that a reduction in substance-related symptoms was accompanied by improved levels of functioning, social adjustment and enhanced quality of life, provides further support for this point.

In conclusion, there is some preliminary evidence that A-CRA is a promising treatment in the rehabilitation of adolescent substance users in Ireland and culturally similar societies. Clearly, results from a case study have limited generalisability and there is need for larger controlled studies providing robust outcomes to confirm the efficacy of A-CRA in an Irish context. A more systematic study of this issue is in the interest of adolescent substance users and the health services providers faced with the challenge of providing affordable, evidencebased mental health and addiction care to young people.

13. Recommendations to Clinicians and Students

The ACRA model is a structured assemblage of a range of cognitive and behavioural activities (e.g. a rationale and overview of the paradigm, sobriety sampling, functional analyses, communication skills, problem solving skills, refusal skills, jobs counselling, anger management and relapse prevention) which are shared in varying degrees with other CBT approaches. The ACRA model has the advantage of established effectiveness. A foundation in empirical research together with its manual- supported approach results in it being an appropriate “off the shelf ” intervention, highly applicable to many adolescent substance misusers. Such a focussed approach also has the advantage of limiting therapist “drift”. Notwithstanding the accessible manual and other resources available on- line, clinicians and students are strongly encouraged to undergo accredited ACRA training and supervision.

Unfortunately such a structured model, despite its many advantages, does have limitations. This model may not meet the sum of all drug misusing adolescent service user treatment needs, nor is it applicable to all adolescent drug users, particularly highly chaotic individuals with high levels of co- morbidities or multi-morbidities as often found in this population [29 , 30] . Whilst focussing on specifically on drug use, ACRA does not directly address co-existing problem behaviours or challenges such as depression, anxiety, personality disorder, or post traumatic stress disorder (PTSD) synergistically linked to drug use. It is possible that given the high levels of dual diagnoses encountered in this population as well as the compounding effect that drug use exerts on multiple systems, clinicians and practitioners may find a strict application of the ACRA model limiting, necessitating the application of an additional range or layer of psychotherapeutic competencies? Additionally the ACRA model does not focus explicitly on other psychological activities useful in the treatment of drug misuse such as the control and management of unhelpful cognitive styles or habits; breathing or progressive relaxation skills; anger management; imagery, visualisation and mindfulness. That is, as a manual based approach comprising a number of fixed components, a major potential challenge facing clinicians and students is the tension they may experience between maintaining strict fidelity to a pure ACRA approach, versus the flexibility l approved by more formulation driven CBT approaches?

The advantages of a skilled application of a formulation driven approach which are cited and summarised in are multiple and include the collaborative nature of goal setting, the facilitation of problem prioritisation in a meaningful and useful manner; a more immediate direction and structuring of the course of treatment; the provision of a rationale for the most fitting intervention point or spotlight for the treatment; an integration of seemingly unrelated or dissimilar difficulties in a meaningful yet parsimonious fashion; an influence on the choice of procedures and “homework” exercises; theory based mechanisms to understand the dynamics of the therapeutic relationship and a sense of targeted and ‘extra-therapeutic’ issues and how they could be best explained and managed, especially in terms of precipitators or triggers, core beliefs, assumptions and automatic thoughts.

Thus given the above observations and together with the importance placed on engagement and retention, the high variability in the cognitive, emotional, social and developmental domains [4] differences in roles (e.g. teenagers who are also parents) and levels of autonomy as well as high degrees of dual diagnosis or co- morbidities found in this group [29 , 30] practitioners are encouraged to also develop competencies in allied psychological treatment models such as Motivational Interviewing [31] ; familiarity with the core principles of CBT, disorder specific and problem-specific CBT competences, the generic and meta- competences of CBT as well as an advanced knowledge and understanding of mental health problems that will provide practitioners with the confidence and capacity to implement treatment models in a more flexible yet coherent manner,. In addition to seeking supervision and mentorship students and practitioners are directed, as a starting point, to University College London’s excellent resources outlining the competencies required to provide a more comprehensive interventions [11] .

Both authors reported no conflict of interest in the content of this paper.

Author Contributions

Conceived and designed the experiments: JI. Recruitment & assessment and on going treatment t of patient JI. On going supervision of case KD. Contributed reagents/materials/analysis tools: JI, & KD. Wrote the paper: JI. Contributed to final draft paper KD.

Acknowledgments

We thank Adolescent Addiction Services, Health Service Executive.

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Challenges in addiction-affected families: a systematic review of qualitative studies

Mostafa mardani.

1 Department of Social Work, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

Fardin Alipour

2 Department of Social Work, Social Welfare Management Research Center, Social Health Institute, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

Hassan Rafiey

3 Social Welfare Management Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

Masoud Fallahi-Khoshknab

4 Department of Nursing, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran

Maliheh Arshi

Associated data.

All data generated or analyzed during this study are included in this published article.

The relative paucity of research on Addiction-Affected Families’ (AAF) issues and the lack of attention given to their difficulties and treatment in interventions and clinical practices indicate that the primary focus consistently revolves around individuals with addictive disorders, even when the treatment process involves their families. However, it is believed that family members endure significant pressures that result in extensive negative consequences on the personal, familial, and social aspects of their lives. Aiming for a better understanding of the challenges and issues that AAF’s experience, this systematic review explored qualitative studies with a focus on the impact of addiction on different aspects of families.

We searched Research Gate, Scopus, Web of Science, ProQuest, Elsevier, and Google Scholar Databases. We included studies of qualitative design which have investigated the effects of addiction on families. Non-English language studies, medical views, and quantitative approaches were excluded. Participants in the selected studies included parents, children, couples, sisters/brothers, relatives, drug users and specialists. The data from the selected studies were extracted using a standard format for the systematic review of qualitative research (the National Institute of Health and Care Excellence [NICE] 2102a).

A thematic analysis of the findings of the studies identified 5 main themes: 1) initial shock (family encounter, searching for why), 2) family in the fog (social isolation, stigma and label), 3) sequence of disorders (emotional decline, negative behavioral experiences, mental disturbance, physical degeneration, family burden), 4) internal family chaos (instability of relationships, shadow people, erosive confrontation with the drug-using member, a newly emerging member, collapsing system, financial collapse), and 5) self-protection (attracting information, support, and protective sources, coping and adjusting the effects, the emergence of spirituality).

This systematic review of qualitative research highlights the various and complex issues which addiction-affected families go through in terms of financial, social, cultural, mental and physical health problems, as a result of which experts of the field are needed to investigate and take measures. The findings can inform policy and practice and the development of interventions aimed to lighten the burdens which addiction-affected families carry.

Today, due to the expansion of societies, the emergence of various social groups, and the diversity of needs, countries and the general public have faced a new world of needs, interests, progress, and even various problems. These issues and problems have penetrated the spirit of societies and have influenced individuals’ social world. In addition to the effects on the individuals, such problems have also had widespread effects on larger levels, such as the family and society levels.

When a family member enters the cycle of problems, the family, as the first group and institution, starts its support services for the individual, and since, in most cases, the family and its members do not have sufficient and specialized knowledge about the individual’s problem, they are under too much pressure. Maintenance, care, and support of a member with an injury and problem put a heavy burden on the shoulders of families, and since some families are not able to adapt to the problem and react appropriately to it, the family’s normal system and functioning are disturbed, and the family deviates from its normal path due to the severity of the problem [ 1 , 2 ]. Addiction is one of the biggest social problems that the current world is facing. It is a problem that does not only involve the drug user but also affects several individuals and social environments around the person [ 3 , 4 ]. Studies have shown that the impacts of drug and alcohol use on families are undeniable [ 5 – 7 ] and exposes family members to a wide range of issues such as: socio-economic and mental health problems, abuse, conflicts, dysfunctional family structure, various issues in community life, and several problems related to married life [ 8 ]. It is noteworthy that in the absence of sufficient social and governmental support, the burden of addiction or any other problem will be quite heavy and stressful for families, which, in addition to affecting the structure as well as the function and role of the family, makes family members face various and severe pressures and stresses [ 9 – 11 ]. Of course, it is essential to mention that the various effects of addiction in different cultures and also the drug user’s role in the family (wife, parent, or child) are not to be ignored [ 12 ]. Although such families suffer from the same pain, the severity of the challenges they face vary in different cultures [ 13 ].

Despite the abundance of research on addiction and its implications for individuals, there is a dearth of comprehensive understanding regarding the distinctive challenges faced by families affected by addiction. Although studies have provided valuable insights into the personal experiences of individuals grappling with addiction, a substantial gap still exists in the current literature when it comes to exploring the specific challenges, dynamics, and coping mechanisms within families affected by addiction [ 14 , 15 ]. In other words, such studies fail to notice the other side of addiction, which is addiction-affected families [ 16 ].

In addition, those other studies which do in fact investigate the challenges faced by addiction-affected families, have not comprehensively examined them and have targeted only limited parts of AAF’s experiences. For instance, in one study, only certain single challenges in isolation was considered [ 17 ], and in another paper, the effect of relationship, social and cultural factors on the AAF’s experiences were investigated [ 13 ]. Furthermore, the only existing qualitative review in this field reviews the qualitative studies on addiction-affected families until the year 2010 [ 18 ]. This is while the challenges faced by such families in recent years are beyond the ones investigated in these studies, and a comprehensive view on the problems faced by this group of people in all dimensions is still missing.

For these reasons, further research is needed in the field of AAF, so that they can ultimately lead to a change in the perspective of therapeutic measures and theoretical models in this field. By conducting comprehensive and detailed investigations a deeper understanding of AAF can be attained, which in turn has the capacity to reshape current perspectives and contribute to the advancement of this field [ 19 ]. The purpose of the present systematic review is to identify and gain a comprehensive view of qualitative studies and gain insights into the similarities and differences existing in the shared human experience of the same phenomenon through evaluation, critical analysis, and synthesis of qualitative results based on observations and main concepts in order to use the obtained data to make it possible to provide services and interventions in the area of ‘rehabilitation of addiction-affected families’. Since families play a significant role in the treatment process and a comprehensive study on the challenges that families face and the interventions and treatment processes which are most effective for them has not yet been carried out, the present study can pave the way to respond to the above-mentioned conditions.

The present study

What distinguishes qualitative research from quantitative research is their ways of looking at various phenomena and searching methods. In other words, qualitative research seeks to investigate the experiences of addiction-affected families regarding the addiction of one of their family members and subsequently gain deep insight into the phenomenon in question. In this way, qualitative research provides understanding and insight regarding the effects of addiction on families by examining the thoughts and feelings of the participants and analyzing the extracted themes [ 20 ]. The main goal is to provide a comprehensive understanding of the differences in human experiences regarding a phenomenon by analyzing and reviewing texts, images, and interviews. Qualitative research provides valuable insight into phenomena, policies, and practices, although such research traditionally had no place in systematic reviews [ 21 ]. The importance of developing a client-based policy was internationally accepted and recognized by clients themselves. Paying attention to the voice of clients means giving them enough power to express their issues and problems (having a voice) [ 22 ]. Addiction-affected families are often isolated and are somehow service receivers due to the many challenges and problems they face, and this makes them choose different ways to reach a solution, and on this path, they come across multiple issues and difficulties; as a result, if we want to achieve a correct and integrated understanding of the problems of addiction-affected families, it is necessary to conduct qualitative research. The main focus of this systematic review is to provide a general and comprehensive view of addiction-affected families and the issues and problems this group have when confronting the drug-using member. In particular, the present study aims to identify the gaps and analyze the issues and themes from different types of qualitative research to be aware of the services and actions needed for addiction-affected families in different dimensions.

Search strategy and criteria

The search strategy was restricted to studies published in English regarding the effects of addiction on families published between 1990 and 2022. In the search strategy, Research Gate, Scopus, Web of Science, ProQuest, Elsevier, and Google Scholar databases were used and analyzed from 1990 to January 2022. The keywords selected for international databases included: Addiction-affected family, the impact of addiction, addiction and drug abusers, Impact of addiction on families, negative consequence of addiction on families, addiction and family. The papers were first reviewed based on the titles and abstracts. In order to identify relevant studies for the present systematic review, inclusion and exclusion criteria were considered. For this review, a three-stage selection process was used to apply the inclusion and exclusion criteria [ 23 ]: 1- Looking at the title, 2- examining the abstract to identify its association with the research question and method, and 3- reviewing the entire paper.

Based on titles and abstracts, papers were excluded if they did not explore the experiences of addiction affected families or the effects of addiction on family members; exploration of AAF’s experiences and the effects of addiction on family members was required to be either an aim of the study or a substantial finding in the results. To ensure an in-depth understanding and a rich description of experiences, only studies presenting primary data using qualitative methods were included. Mixed-method studies were included if qualitative findings were presented separately. Searches were limited to publications in the English language. Studies were excluded, if papers were restricted to individuals with/suffering from addictive disorders, and if papers were related to family factors of addiction. These exclusion criteria were introduced in order to ensure that experiences and views were current and related to the target group’s (AAF) experience. Any book chapters, Interventions, commentaries, letters, reviews, first-person accounts, and abstracts were excluded. In addition to the mentioned cases, the reference lists of the obtained studies were also examined to identify the studies that were not obtained using the above methods.

In cases where the researcher was not certain about the inclusion criteria of an article, the intended article was kept for the next screening stage. Based on the search strategy of the texts, 518 studies were initially identified. An additional manual Google search was performed at this stage, and 14 more studies were identified. After removing duplicate cases and reviewing the titles and abstracts of these studies, 479 cases were removed and 53 cases were assigned to determine the inclusion criteria. After a removal process, a total of 25 studies were selected as eligible studies (Table ​ (Table1). 1 ). An overview of the search steps can be observed in the PRISMA flowchart (Fig.  1 ). The 25 studies include two studies with a combined method, and one International report of a research project whose results of the qualitative thematic analysis contain valuable data in the research process.

Summary of included studies

PRISMA flow diagram

Data extraction

The data of the determined studies were extracted using a standard format for the systematic review of qualitative research (the National Institute of Health and Care Excellence [NICE] 2102a) [ 48 ]. The characteristics identified from each study included research questions, methods, sample size, and quality assessment. The desired data were carefully extracted and organized in relevant tables. In order to synthesize and analyze the findings of the studies, the desired data from the studies were extracted and categorized into specific thematic categories. Subsequently, the patterns present in the findings of the studies were searched and scrutinized to achieve a better and more comprehensive understanding of the issues and problems caused by addiction toward families.

Quality assessment

The quality assessment of the articles extracted from the journals was performed using the NICE quality assessment checklist for qualitative research (NICE 2012b) [ 49 ]. By following this guideline, the conducted assessment investigates the research questions and the robustness of the method concerning the key findings and a valid conclusion. Six main areas are considered and assessed in this guideline: Theoretical approach, study design, data collection, data reliability and validity, analysis method, and ethical considerations. The seventh overall assessment deals with the relevance of the study and provides an overall rating: “ +  + ” in cases where all or most of the checklist criteria have been met and in cases where they have not been met but the conclusion has not been affected; “ + ” where some of the checklist criteria have been met and the conclusion is unlikely to change; and “-” where few or no criteria are met.

Two studies have been included in this systematic study using a combined method, and the quality assessment was performed only on the results of the qualitative data methodology of these studies. Regarding the quality assessment of the present study, a reviewer-researcher initially assessed the quality of the included studies, and the quality assessment was subsequently confirmed by another reviewer. Each search process in the different databases, the initial review of the found documents, matching with the inclusion and exclusion criteria of the findings, and quality assessment were conducted by two researchers independently to increase validity. In this study, the researchers were committed to being sufficiently accurate and honest in using the different sources in all stages of the work, including data collection, data analysis, and the report of the findings. The intellectual rights of all individuals related to the research are fully respected.

This study identified 99 abstracts screened for relevance to qualitative studies on addiction-affected families. Fifty-three full-text articles were studied and assessed, and 25 studies were finally identified as suitable for this review study. The obtained results were organized in relevant tables and classified into specific groups.

Characteristics of target studies

Of the 25 studies in the systematic review, only one analyzed the transcripts of online interviews, and the other 24 studies were results of direct contact with the target groups. The total number of participants in the studies included in this systematic review was 728 people, among whom parents ( n  = 288, 39.56%), couples ( n  = 222, 30.495%), sisters/brothers ( n  = 65, 8. 92%), relatives ( n  = 63, 8.65%), drug users ( n  = 39, 5.35%), children ( n  = 21, 2.88%), specialists ( n  = 20, 2.74%), and female heads of households ( n  = 10, 1.37%) accounted for the largest percentage of participants in the target studies of this research respectively. Also, the number of samples in the studies shows a great variety, from the smallest number of samples in a case study ( n  = 1) [ 35 ] to the largest number of samples in a study ( n  = 113) [ 46 ].

Geographical characteristics

In terms of the geographical distribution and information of the studies included in this systematic review, there are 8 studies conducted in Australia (32%), 4 studies from England (16%), 3 studies from South Africa (12%), 2 studies from Canada (8%), 1 study as a result of collaboration between England and Mexico (4%), and 1 study each for Scotland, Indonesia, Finland, Brazil, Iceland, India, and Italy (4% each).

The quality assessment carried out according to the NICE guidelines among the studies identified for the present research showed that 16 studies were of high quality (64%) and 9 were of medium quality (36%).

Qualitative methods

The most common qualitative methods used in the target studies reviewed in the present study included 7 studies using ethnographic and phenomenological methods (28%), 6 studies using the grounded theory method (24%), 3 studies using the thematic analysis method (12%), the use of the descriptive-exploratory method in 2 studies (8%), and 2 studies using the content analysis method (8%). In the remaining 5 studies (20%), various qualitative methods have been used, including 1 case using deviant case analysis in a study in Scotland with 74 samples of relatives, parents, and experts of the drug abuser [ 27 ], 1 case using the qualitative-analytical-exploratory method [ 30 ], 1 case study of 10 female heads of families [ 8 ], 1 case study of a mother with a child with drug abuse that has been analyzed using the interpretive phenomenological method [ 35 ], and 1 case using the framework analysis approach [ 40 ].

Thematic analysis of results

In order to analyze primary qualitative data, the thematic analysis approach is often used [ 50 ]. This approach is also an applicable method which can be used to synthesis the findings of multiple qualitative studies [ 51 ]. The synthesis will surpass the content of the original studies and generate further conceptions or understandings through developing the analytical themes [ 51 , 52 ]. The following three stages of thematic synthesis, planned by Thomas and Harden [ 51 ], were used: (1) Free line-by-line coding of the findings of the primary studies, (2) the organization of ‘free codes’ into related areas to construct descriptive themes and (3), finally, the development of analytical themes. In this synthesis, the published results from each of the included studies were coded. A thematic analysis of the findings of the studies identified 5 main themes: 1) Initial shock (family encounter, searching for why), 2) family in the fog (social isolation, stigma and label), 3) sequence of disorders (emotional decline, negative behavioral experiences, mental disturbance, physical degeneration, family burden), 4) internal family chaos (instability of relationships, shadow people, erosive confrontation with the drug-using member, a newly emerging member, collapsing system, financial collapse), and 5) self-protection (attracting information, support, and protective sources, coping and adjusting the effects, the emergence of spirituality). The visual outline of the identified themes can be seen in Fig.  2 . The frequent themes identified in the articles include the sequence of disorders in 22 studies, internal chaos in 18 studies, self-protection in 13 studies, family in the fog in 13 studies, and initial shock in 7 studies (Fig.  2 ).

Diagram of identified themes

The first theme (initial shock) is one of the themes identified from analyzing the findings of the studies consisting of themes such as family encounter and searching for why. Confusion, anger, inability, and dysfunction due to the family’s initial effort to respond to the raised problem are among the things that are mentioned in Barnard’s study [ 27 ], which uses the deviant case analysis method. Also, in a study to investigate the experiences of parents, Hoeck [ 29 ] investigated how parents are informed of their children’s addiction (being informed by a third party (police or hospital)/ by the drug user and the parents themselves) and showed that the families’ knowledge about addiction was very little at first or they had no information about it and there was no free discussion to express such problems in the home environment. Another study by Salter et al. [ 34 ], using the grounded theory method in England, showed that families suffered from difficulties such as confusion in the initial encounter with a problem and experienced problems like lack of awareness, the gradual process of awareness, drug user’s deceptive behavior, denial, self-contradictions, and the effects of external factors in the initial encounter with the addiction problem of one of their members. Investigating the process of parents’ adaptation and coping with a drug-abusing teenager was one of the goals that Choate [ 36 ] sought in a study using the grounded theory method. The results of the mentioned study indicate that the family first faces the way of becoming aware of their child’s drug addiction and perceives it as an intensified and progressive problem and then tries to find a logical answer for the cause and reasons for such a problem. At the same time, many parents proceed with examining their own behavioral records, and some parents consider their drug use experiences as a trigger and factor for their child’s drug addiction. In a study conducted using Ritchie and Spencer’s framework approach, Bulter et al. [ 40 ] viewed the family’s way of dealing with the addiction of one of its members as being one of the following cases: A person’s voluntary confession of drug use, observing abnormal behavior or changes in their normal behavior, denial of their drug use, difficulty recognizing, family devastation because their child is using drugs, experiencing it as a very shocking and traumatic event, experiencing it as the greatest fear, feeling defeated, self-blame, and the feeling of great shame at the beginning of facing the addiction problem. It is worth mentioning that the determination of factors and reasons such as mental health problems or learning problems as triggers and factors of drug dependence were among the explanations and mechanisms mentioned by the participants of Choate’s study [ 41 ] about the initial encounter with the addiction problem. The analysis of Jackson and Mannix’s [ 45 ] findings showed that one of the themes about which the addiction-affected families expressed their experiences was initial exposure and awareness. In this descriptive-exploratory study, the participants described their initial awareness of their child’s addiction with the sentence, “I could not deny that this had happened.” Generally speaking, the initial exposure and the way of awareness and then trying to respond to the addiction problem are among the negative experiences to which addiction-affected families frequently pay attention.

The second theme (family in the fog), with themes such as social isolation and stigma and label, is among other themes identified by qualitative analysis of the findings of the target studies. Regarding the stigma and label theme, in a study conducted via the phenomenological method to investigate the experiences of families with drug-using children, Wiarsih et al. [ 24 ] considered the family’s labeling one of the results of having a drug-abusing child. The findings of the mentioned study show that society’s attitude and feedback, self-view, and social discrimination are among the things that families perceive under the title of stigma. In this regard, in a qualitative-analytical and exploratory study on addiction-affected families, Rodrigues [ 30 ] has viewed society’s prejudice and society’s experience of stigma by the families to be of the factors that change the lives of families with drug-using members. The experience of stigma as one of the stressful factors at the level of families’ extended interactions is one of the findings of a study by Salter [ 34 ] in England using the grounded theory method. Among other themes identified in the present study is the social isolation of addiction-affected families. One of the negative experiences of addiction-affected family members is inhibiting social activities and, in some way, being away from the society and being isolated. Limited activities and social roles, especially for those with the most supportive contact with the drug user, were one of the findings of McCann’s study [ 28 ] conducted in Australia. In addition, in another study carried out to investigate the experiences of families regarding dealing with social isolation, McCann [ 25 ] showed that one of the families’ measures in dealing with the addiction of their family members was to minimize contact with others and consequently face things such as shame and embarrassment, fear of being judged by others, self-quarantine, and unwillingness to access informal and official support. In this regard, in a study carried out by the thematic analysis of 100 transcripts of online interviews with couples, Wilson [ 32 ] presented the impact on the family social network and the challenges of families in this area as one of the main themes of his research. In another work of research by Arlappa et al. [ 8 ], which was conducted in India as a case study, the effects of a drug-using member on a family’s social life were presented as one of the results of the study, according to which families prefer to limit their social interactions following the addiction of one of their members. In a study to examine the effects of addiction on family from the parents’ perspectives, Salter [ 34 ] analyzed the data obtained from semi-structured interviews using the grounded theory method. The findings of the mentioned study show that addiction-affected families are disturbed in the broad and essential levels of their interactions, which will result in the disassociation of such families from the social world and lack of active participation by those families. Also, many families will face the challenge of getting help because they try to hide the addiction problem of one of their members and thus limit their communication and experience serious challenges regarding asking for help and support [ 36 ]. It should be mentioned that the challenge of asking for help and the weak support of addiction-affected families are due to hiding the problem from others and disassociating from others, which is also one of the findings of Arcidiacono’s study [ 46 ] in Australia. Isolation of the family is another finding in this section, to which Jackson [ 37 ] refers in the findings of his study in Australia as the main theme of isolated, disgraced, and humiliated as if the family is only with the drug user and has no other social connection. This concept is also expressed in the results from Ahuja’s study [ 47 ] under the title of social isolation and also in the results of Bulter’s study [ 40 ]. The results from Bulter’s study indicated that self-imposed experiences, the family’s feelings of embarrassment or shame due to drug use by one of their members, and worrying about others’ opinions played a significant role in the isolation of family members and parents.

The third theme (sequence of disorders) is completed with themes such as emotional decline, negative behavioral experiences, mental disturbance, physical degeneration, and family burden. The findings of the present study showed that family’s emotional dimension is severely affected due to the abuse of one of its members, and families experience a wide range of emotionally distressing situations. The feelings of disbelief, non-acceptance, disappointment, shame, shock, anger, and regret in the family are mentioned in the findings by Wiarsih et al. [ 24 ]. Furthermore, the findings of Incerti’s study [ 26 ] have indicated feelings of sadness, hopelessness, and distrust as the fundamental challenges against addiction-affected families. Fatigue and emotional exhaustion, as well as fear and despair about the future in addiction-affected families, were mentioned in the results of an interpretive phenomenological analysis of 31 semi-structured interviews in McCann’s study [ 28 ] in Australia. Feelings of helplessness and despair, desperate cries for help, and living with guilt are feeling which are typical examples of the emotional distress experiences of addiction-affected families, which were found by various studies [ 29 , 35 , 38 , 41 , 44 ]. Families naturally experience a wide range of emotions, a significant part of which are positive emotions. However, in his study to investigate the experiences of addiction-affected families in Iceland with 16 participants, Ólafsdóttir [ 33 ] showed that one of the negative experiences of addiction-affected families was the transformation of their positive feelings, such as worry and care, over time to negative emotions, such as anger, shame, and sadness. Also, the increase in negative feelings toward the drug user, the increase in negative feelings caused by the drug user, and the increase in negative feelings in general (confusion, etc.) in Salter’s study [ 34 ], emotional distress and the use of pills to moderate stress in Groenewald’s study [ 35 ], and variable emotions shifting from positive components (love, admiration, and care) to negative components (desire for separation, etc.) in Velleman’s study [ 43 ] are among other findings in this regard. By analyzing the findings of the target studies, it was found that negative emotional experiences in families with addiction problems were widespread. In addition to the mentioned cases, there were cases such as worry and uncertainty about the individual’s situation, the family’s status, the family’s future, the effects of the individual on the family [ 34 , 43 , 46 ], loss of trust and feeling of mistrust [ 37 , 46 ], feelings of blame and shame [ 37 , 38 , 41 , 44 , 46 ], feelings of fear and trembling of family members [ 44 , 45 ], feeling of sadness due to the drug user’s negative and unexpected path [ 38 ], the emergence of destructive emotions such as inferiority, anger, division, and separation [ 39 ], negative effects on individuals’ emotional health, and the emergence of a wide range of negative emotions from continuous crying to the feeling of separation and leaving the family [ 40 ]. Negative behavioral experience is one of the other themes identified in the present study. Experiencing aggression and verbal or physical violence [ 25 , 27 , 29 , 33 , 37 , 46 , 53 ], theft [ 27 , 30 , 41 ], tension and controversy at home [ 34 ], and experiencing domestic violence towards household members and items [ 47 ] are among the cases mentioned by addiction-affected families in the target studies. Additionally, in the psychological dimension, the families reported negative experiences under the title of mental disturbance. Things like different levels of stress and anxiety [ 27 , 29 , 33 , 53 ], the experience of mental and psychological violence [ 33 ], different effects on mental health [ 34 ], and suicidal ideation and attempt [ 35 ] are among the cases identified from the analysis of the findings of the target studies. The findings from Orford’s study [ 39 ], which was carried out in order to investigate the experiences of stress and pressure in addiction-affected families, indicated that the physical health of families was also affected by the addiction of one of their members, and family members sometimes reported cases such as the emergence of physical weakness, specific physical symptoms, excessive fatigue, lack of sleep, and anorexia. The incidence of physical degeneration was also identified and investigated in the findings of other studies [ 34 , 40 ]. In addition to the mentioned cases, families also have an unpleasant experience under the title of family pressure and burden as a result of the drug abuse process of one of their members. The analysis of the findings of the studies showed that physical, psychological, social, and economic burdens [ 24 ], high levels of tension and pressure during the treatment of the drug-using member [ 34 ], and long-term processes of treatment and rehabilitation [ 36 ] were among the things experienced by addiction-affected families in this regard.

The fourth theme (internal family chaos) was another identified theme completed with the following themes: Instability of relationships, shadow people, erosive confrontation with the drug-using member, a newly emerging member, collapsing system, and financial collapse. The internal relations of families are among the first things which are affected by the newly created conditions, and families experience a wide range of disorders in this area, from problems and differences between parents and extensive marital differences [ 8 , 29 , 47 ] to the disturbance of the general structure of interpersonal relationships at home [ 27 , 30 , 32 , 34 , 40 ]. Also, the occurrence of chaos and failure in family communication and family conflicts are other things mentioned in the findings of the studies [ 41 ]. “Shadow people” refers to family members who have been neglected by others, especially parents, due to the addiction of another member, and the needs and psychological conditions of these individuals are somehow not paid attention to. Being neglected [ 34 ] and being ignored and not approved [ 26 ], being exposed to drugs and the possibility of entering the use process and dealing with public reactions [ 27 ], experiencing negative psychosocial effects, being isolated [ 33 ], suppressed anger and rage [ 37 ], lack of affection and attention, as well as reluctance towards social interactions and bringing friends to the home environment [ 47 ] are among the issues mentioned in various studies. In dealing with the drug user, the families also tried different ways, and the analysis of the findings showed that a significant part of the families’ energy is spent on these efforts. Rejection of the drug user was one of these ways that Barnard [ 27 ] found in his study in Scotland, and Orford [ 39 ] referred to it in his study as “an unpleasant life with the drug user.” Controlling the person and setting various limits for the drug-using person were other ways used by the families to deal with their drug-abusing member. Worrying about the person, trying to protect the person, and maintaining the relationship with love and friendship were other actions by the families in this area [ 38 , 45 ]. Also, the participants of Arcidiacono’s study [ 46 ] stated that the person was good but had terrible abuse, and with this view, they confronted their drug-abusing member as if a new person had emerged who had nothing in common with the previous one. The new person was a person whom the family did not trust, had not been at home in general as if he/she was missing, had left the house without any notice and the time of their return was not known, did not take any family rituals and gatherings (birthdays, Nowruz, etc.) seriously and was absent in them, had a noticeable inability to respond to the family’s expectations [ 43 ], their friends had changed in general, and they suffered a sharp drop in education, as well as a decrease in personal hygiene and physical health [ 44 ]. It is worth mentioning that due to these issues, families tend to have serious problems in family economy and financial capability and experience a kind of financial collapse [ 8 , 28 , 30 , 33 , 34 , 39 – 41 , 46 , 53 ]. Facing harmful family dynamics [ 28 ], threatening family functioning [ 29 ], jeopardizing the family system’s health[ 8 , 33 , 40 , 44 – 46 , 53 ], and moving from cohesion to confusion and collapse [ 46 ] are other threats that put the family on the path to internal chaos.

The fifth theme (self-protection) is related to the actions that families have taken to deal with new conditions. Themes such as attracting support sources, coping and adjusting the effects, and the emergence of spirituality are included in this category. In his study, Wiarsih [ 24 ] showed that the families tried to cope with the problem by attracting moral, financial, informational, and social support. In order to attract support sources, the findings of various other studies were also considered in this research. These findings showed that the attraction of support, informational, and therapeutic sources had been one of the dominant methods of encountering the addiction problem in the addiction-affected families studied [ 26 , 29 , 34 , 40 , 44 , 46 ]. Among other actions of addiction-affected families to protect themselves are coping and adjusting the effects, such as problem-solving methods [ 24 ], dealing with violence [ 25 ], adjusting the effects of stigma [ 31 ], and various coping strategies to reduce the consequences of the addiction of a family member [ 29 , 34 , 38 , 41 , 44 , 46 ]. Also, Rodrigues [ 30 ] showed in his study that faith and trust in God was one of the methods used by families to manage the effects of the problem and deal with it.

Although qualitative research on the issues and problems of addiction-affected families are limited and carried out in minority, these studies have been necessary to improve the understanding and insight of policymakers in this field, social service providers, professionals, and addiction-affected families. Effective and specialized support for this group is possible only when their voices are heard, and services are tailored to their conditions, and needs are noticed and provided for. For this purpose, this systematic review was conducted to identify and review those studies which have investigated the effects of addiction on addiction-affected families using qualitative research methods. The findings of the studies showed consistent themes among the research methods and the studied populations. Twenty-five high-quality and medium-quality articles with diverse contents which were suitable for the purposes of the current research were identified and reviewed. The analysis of the findings of the studies showed 5 main themes related to the fundamental challenges of addiction-affected families. The identified themes were the initial shock, family in the fog, sequence of disorders, internal family chaos, and self-protection. The initial encounter with addiction was one of the first themes of the present study. Families are initially confused and shocked due to lack of knowledge and experience [ 27 , 29 , 34 , 40 ] and are somehow unsure of their next steps to take. Some families start self-prescription and take actions that they consider appropriate, which creates the background for future problems for family members. At this stage, the family puts itself in a deep, long, and recurring mourning process [ 24 ]. This concept is very specific and has been mentioned in very few studies. In other words, encountering a family member’s addiction for the first time is so painful that families refer to it as their hardest experience in the addiction process [ 54 ]. Generally, Placing families on educational grounds and introducing support groups can play a significant role in getting families out of this vicious cycle. These groups play a significant role in modulating the effects of the initial shock in addiction-affected families by providing information about addiction and treatment, strengthening the morale of addiction-affected families, providing support, understanding their needs, providing a learning contexts, teaching family members to distance themselves from problematic situations, helping them overcome feelings of guilt, shame, and failure, teaching them to deal with risks and fears, and teaching coping strategies (physical and emotional distance of the family from the drug-abusing person). Furthermore, the key sentence of support groups for families is: Learn to live with anxiety and fear [ 29 ].

The analysis of the findings showed that families opt for social isolation to avoid social stigma and being labeled. These two processes have been described in the present study with the second theme, i.e., family in the fog. The most important challenge that these families experience at this stage is the challenge of getting help [ 36 ], because they generally pose an unwillingness to access formal and informal support available in the society [ 31 ]. This action of the families is taken due to the defense mechanism of secrecy. Families somehow prefer to respond to the problem on their own in any way possible in order to avoid the possibility of judgment [ 31 ], stigma [ 34 ], and being labeled, so that they can avoid social discrimination against the family [ 24 ]. In this regard, some families move toward social isolation and some try to manage the effects of this problem by adopting measures such as adjusting the effects of stigma, challenging the misconceptions of the people around them about drug abuse, or choosing specific individuals and communicating with them [ 31 ]. Furthermore, the experiences of shame, stigma, and social isolation are among the results which Di Sarno et al. [ 17 ] found in their study, which was conducted via the scoping review aiming to investigate the mental and physical problems faced by addiction-affected families. In their study, in addition to quantitative studies, they also aimed at those qualitative studies which specifically focused on the mental and physical challenges against addiction-affected families and found the three above-mentioned challenges to be common among all the investigated qualitative studies. What is expected to be noticed by policymakers and service providers is to eliminate the misconceptions about addiction-affected families. Support groups should compile and implement effective measures to adjust and finally remove the effects of social stigma. Also, the development of effective interventions at the individual and social levels by researchers in this field aiming at removing the social barriers against addiction-affected families can play a significant role in preventing the social isolation of this at-risk group.

The third and fourth themes identified in this study indicate the extent of harm in the family, both at the family health level and the family system and functioning level. Concerning the various aspects of the health of addiction-affected families, studies focusing on this area provide insights into the consequences of damages to emotional, mental, physical, and behavioral health of families with a drug-abusing member, showing the sequence of damages for addiction-affected families. The concept above is among the concepts which have been mentioned in various studies. In other words, addiction deeply affects family members on the psychological, emotional, physical, and behavioral levels [ 55 – 57 ].

Furthermore, concerning the fourth theme, i.e., internal chaos, this study determined that the family system and functioning might face serious threats at the levels of relationships, as well as in the family health system. Conflicts within the families affected by addition are among the challenges which all family members have mentioned and considered to be an indispensable part of addiction. It is to be noted that improper construct and function of a family and morbid relations between family members cause them to face more severe challenges and pressures [ 13 ]. Since different levels of family health and function are influenced in the third and fourth themes and all of the reviewed studies have taken them into account, it seems necessary to take measures in order to alleviate their effects.

Specialists consider family a source and support for its members, who fulfill their duties with all their limitations [ 27 ]. The results of the investigations showed various interventions around the world with different goals for addiction-affected families, and their implementation can play a key role in helping families exit this Bermuda process. Increasing social support, coping skills, modulating stress and pressure [ 58 ], reducing the symptoms of mental disorders and improving family functioning [ 59 ], improving family functioning at the system, structure, and strategy levels [ 60 ], training families in the areas of emotional support, social acceptance, reduction of problems caused by addiction [ 61 ], awareness of family needs, environmental and interpersonal changes, organization of family structure, use of social strengthening and family education models (craft) [ 62 ] and Matrix [ 63 ], participating in Naranan meetings for addiction-affected families, and participation in meetings are only part of the existing interventions for promoting and improving addiction-affected families. It is worth mentioning that one of the things that the experts in this area emphasize is the necessity to pay attention to those individuals who are at home under the shadow of the drug-using person. In other words, families, especially parents, neglect others due to the problems caused by the addiction of one of their members and spend all the energy and internal resources of the family (financial, mental and psychological, social, and cultural) on the mentioned person. This issue creates severe problems in the long run for other family members due to daily encounters with these issues and facing addiction to such an extent that may cause these individuals to suffer from severe psychosocial problems and isolation [ 53 ] or enter the path of drug use [ 27 ]. Since this systematic review has targeted all the qualitative studies conducted in the field of addiction-affected families and has identified valuable and comprehensive themes, the need to develop a comprehensive intervention according to the data of the present study, taking all dimensions of families into account, has become ever more evident.

As the final theme identified, self-protection is the main key to starting the recovery process in addiction-affected families. Seeking help, moral support, financial support, informational support, and social support [ 24 ] and trying to deal with the problem and reduce its negative effects are parts of the process that addiction-affected families embark on for self-protection. It is to be noted that lack of social support exposes families to serious problems [ 13 ]. The final concept in this section is the recovery process of addiction-affected families, which starts when they face the addiction of one of their members and are somehow involved in its maze. Intervening in the levels of compatibility with the drug user’s behavior, financial compliance with conditions, hidden interventions, formal and informal support, religious and spiritual support [ 12 ], and preparing for changes in family members and family functioning and increasing coping skills [ 64 ] all play an effective role in providing a context for families to protect themselves and ultimately lead to the recovery of families.

In general, the point revealed in this study and mentioned in all reviewed studies was that when the families expressed the challenges caused by addiction, they also expressed their efforts to overcome the problems and called it the challenge that addiction had created for them. In other words, the families tried to survive and keep their family members alive while they were frustrated and exhausted and provided the basis for the family’s recovery. Moreover, it is to be taken into account that the experience of addiction varies for different families based on social and cultural conditions, and provided that there is proper social support and healthy family functioning, family members will face less serious challenges when having to deal with the addition of one of the members [ 13 ]. However, they had doubts about how to do it, and they were prone to confusion and ambiguity. Investigating the recovery process of families is not one of the goals of this study, but it is a topic that can be considered for future research and used as a guide, reference, and path for the recovery of addiction-affected families.

The method for the present study is the systematic review of qualitative studies in the area of experiences and challenges faced by family members affected by addiction. In order to analyze the data, a thematic analysis was used. This study was designed in such a way to analyze only those qualitative studies which comprehensively address the challenges which addiction-affected families face and possess the required standard in accordance with NICE quality assessment checklist for qualitative research. Among those studies which can be compared with the present study, one can mention the valuable study conducted by Di Sarno et al. [ 17 ], in which the researchers implemented the scoping method in order to investigate the mental and physical challenges faced by addiction-affected families. In that study, with respect to the aim of the study, all qualitative and quantitative studies which only focus on the mental and physical challenges against families affected by addiction are analyzed. However, the present study has adopted a more comprehensive approach in order to present, in addition to the concepts above, all the other dimensions of addiction-affected families and to use thematic analysis in order to put forward family challenges comprehensively in 5 different conceptual categories. The present study has taken a step beyond Orford’s review study [ 18 ]. Orford has presented a summary of qualitative studies conducted in the area of addiction-affected families until 2010 and reported the results in the four categories of stress, strain, coping, and social support. The present study, however, has analyzed all the research conducted until 2022 on the challenges faced by addiction-affected families and has presented 18 sub-themes in addition to its main 5 themes.

Limitations and future directions of research

The present study was conducted using a protocol-oriented process and all the reliable scientific databases in the world. While, the concept of addiction includes a wide range of addictive behaviors, addiction in this research meant using any drug and alcohol. There are many limitations to the studies used in this research.

In the present study, the level at which a family member in engaged in substance use (low-risk drug users or occasional users compared to those users classified as harmful or dependent users) has not been considered, while this level can affect the challenges and difficulties faced by addiction-affected families. Three of the studies included in this review were published by the same authors and used the same group. However, each study addressed slightly different aspects of AAF’ experiences with living with a member with addiction problems [ 25 , 28 , 31 ]. It is important to mention that this study has not examined the families’ cultural, religious, and belief differences in dealing with addiction, and the lack of data and studies among different cultures and beliefs in this field is challenging for researchers. As a result, future studies should be able to show a better understanding of the psychosocial effects of addiction on families with more emphasis and sensitivity toward culture, ethnicity, and religion. Moreover, lack of attention to the role of the drug-using member in the family in the current study, can be effective regarding the type of its effects on other family members and other cases that can generally limit the conclusions that can be obtained from this study. For this reason, to produce more reliable results, future systematic studies should limit their search terms and phrases according to the role of the drug user in the family so that they can provide more reliable recommendations and suggestions to support addiction-affected families. Evidence shows that some studies, for various reasons, have more chances to be published in valid journals in the shortest time, and it is somehow easier to access and find such articles, while these articles may be poor in terms of both methodology and work processes. Therefore, in the current study, conclusions solely based on published studies can be misleading. The terms used in the field of addiction-affected families are diverse, and special titles and unique literature might have been used for some papers, as a result of which, we may have missed a number of relevant but inaccessible studies and future systematic studies should include a broader range of relevant terms to provide a more general insight and perspective regarding this group’s challenges and health status. However, in the present study, it is believed that the use of reliable and diverse scientific databases, double screening of the studies, and a strong search strategy have allowed us to identify all eligible articles. While this study has focused on the effects of drug addiction on families, it has also revealed the existence of a big gap in the knowledge of families affected by other addictive behaviors (Internet, gambling, etc.). It is, therefore, essential to compare and draw existing debates and narratives and their evolution over time to understand addiction-affected families’ challenges better.

In addition to the limitations outlined in Table ​ Table1 1 regarding the examined studies, there are other important considerations that warrant attention. Firstly, since the reviewed studies were qualitative in nature, the common limitation of "limited generalizability" applies to all the studies under investigation. In other words, the findings of the reviewed studies cannot be easily generalized. Furthermore, as most studies relied on help-seeking or service-receiving samples, and the selection of participants was based either on snowball sampling or purposive sampling, their experiences may have been influenced by the type of services they received, making them inadequate representatives for all families affected by addiction.

Implications for research and practice

This is the first systematic review of qualitative research on the challenges of addiction-affected families, which has targeted studies over the past 30 years. Qualitative research provides an opportunity to hear the voices of research participants in order to provide valid empirical and perceptual evidence, which can be used to inform and influence policies and provide mental health services using an evidence-based perspective. This systematic review provides a reference of evidence-based knowledge obtained from qualitative research by drawing the themes and findings of qualitative studies on the challenges of addiction-affected families. The first outcome of the present study in practice can be to pay attention to wider dimensions (social, cultural, economic, and individual) of families. In other words, a drug-using person consciously or unconsciously faces their family with fundamental challenges, and these challenges provide the basis for future problems. For example, while societies try to accept this group, social stigmatization and labeling is an issue that this group constantly faces, and it plays a special role in concealment and self-censorship by families, which subsequently causes more severe problems to arise for them. The second outcome of this study for practice and action is the need to train social, educational, and health service providers in order for them to try to accept addiction-affected family members and provide psychosocial, educational, and preventive services in case of encountering any members of this group. Also, this review study has provided the basis for studies and interventions in this field, and, by providing a visual diagram of the identified themes, it has provided the framework for interventions needed by addiction-affected families for researchers in this field. It is worth mentioning that with access to these rich qualitative data, which were the results of the experiences of addiction-affected families, it is possible to design and implement more effective support and educational mechanisms for families that have just entered this long process.

Conclusions

The analysis of the data obtained from the present research identified 5 main themes in this process: Initial shock, family in the fog, sequence of disorders, internal family chaos, and self-protection. The findings of the present study clearly state that any types of intervention to be carried out within addiction-affected families need to consider all problems and challenges created by addiction. These 5 themes were identified in different studies with different qualitative methods and different target populations. The implications of the present study at the levels of policymaking, practice, and research have also been clearly stated. Addiction-affected families want a space that is far from any judgment and labeling so that they can control their mental, psychological, and social conditions and the society can prevent the initial shock of this group when encountering the addiction of one of its members by arriving on time and providing the right educational services. The voices of addiction-affected families revealed the need for educational, informational, and therapeutic support to improve their coping skills in order to face and moderate the effects of addiction. The results of the present study provide a rich source of evidence-based information to provide the best services and policymaking for addiction-affected families. It is also important to mention that in developing countries and in countries where the governments play a small role in providing welfare for their citizens, individuals and families are intertwined elements, and any problem for each member can significantly impact the whole system. Therefore, paying attention to addiction-affected families in these areas is only in its initial stages, and the need to pay attention to this group has become apparent more than ever.

Acknowledgements

The authors would like to appreciate the researchers of the presented articles for their hard work in applying qualitative research methods to examine the challenges of addiction-affected families.

Abbreviations

Authors’ contributions.

MM contributed to the design of study, conceptualization, data curation, formal analysis, investigation, methodology, resources and visualization. FA contributed to the design of study, conceptualization, formal analysis, and revised the manuscript. HR contributed to the design of the study, screening and revised the manuscript and was the Academic Supervisor. MF was the Academic Supervisor. MA advised and revised the manuscript. All authors read and approved the final manuscript.

Not applicable.

Availability of data and materials

Declarations.

The authors declare that they have no competing interests.

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Teen Cocaine Addiction Case Study: Chloe's Story

This case study of drug addiction can affect anyone – it doesn’t discriminate on the basis of age, gender or background. At Serenity Addiction Centres, our drug detox clinic is open to everyone, and our friendly and welcoming approach is changing the way rehab clinics are helping clients recover from addiction.

We’ve asked former Serenity client, Chloe, to share her experience of drug rehab with Serenity Addiction Centre’s assistance.

Chloe’s Addiction

If you met Chloe today, you would never know about her past. This born and bred London girl is 20 years old, and a flourishing law student with a bright future in the City.

A few years ago though, it seemed as if this straight A student was about to throw away her life, thanks to a  class A drug addiction .

Chloe had a great childhood. By her own admission, school was a breeze for her, with strong academic achievement and social skills making her as successful on the playground as she was in the classroom.

Age 7, Chloe started at a boarding school, and loved having friends around her all the time. With no parents about, Chloe and her friends found themselves invited to house parties. As soon as I could convince people they we 18, they moved on to London’s nightclubs.

It was here where Chloe first came across drugs, and it was a slippery slope to cocaine addiction. She explains: “At 15, I was taking poppers, graduated to MDMA at 16, and then I tried cocaine at our year 13 parties. I got separated from my friends, and found them taking cocaine in a back room. I didn’t want to be left out, so I tried it.” 

Chloe scored straight As in her A levels, and accepted a place at Kings College London to study law. She was introduced to new people, and it seemed that cocaine was available at every place they went. Parties, clubs, and even her new friends were all good sources of a line of cocaine. As a self confessed wild child by this point, Chloe didn’t want to miss out.

The demands of a law degree were high, but so was Chloe’s desire for more cocaine.

Going out almost every night to snort coke, she started to wonder if she was becoming an addict. She spent every penny of the generous allowance from her parents. Chloe spent every penny available on credit cards, and even took on a £2000 bank loan to support her habit.

Chloe estimated that at one point, her addiction had saddled her with more than £13,000 of debt.

Coming out of Addiction Denial

Chloe’s light bulb moment finally came when her best friend, who she shared a flat with, sat her down and asked why they were drifting apart.

Chloe realised that cocaine had become more important to her than her friends, family, and studies. It had to stop. Chloe found the details for Serenity Addiction Centres, and called the same day to ask for help with her addiction.

One thing Chloe particularly appreciated about Serenity Addiction Centres was the flexible approach of the counsellors . They got to know Chloe, listening to her worries, and working out a non-residential rehab plan for her. This allowed her to continue with her studies.

Chloe’s treatment was organised at a clinic not far from her university, allowing her to keep her studies on track, and keeping her life as normal as possible.

Chloe says: “Talking about how I was using cocaine, along with contributing problems from earlier in my life, were a massive help. I didn’t want to be known just as a party girl”.

“If I’d not found Serenity Addiction Centres, there would probably have been a long wait for NHS treatment. Serenity Addiction Centres got the right treatment. Everything was organised with privacy and discretion. I only shared what was happening with my flatmate.”

This level of discretion was really helpful, and the rapid results of her treatment meant that after just three months Chloe felt able to tell her parents what had been happening. 

Life after rehab

It’s amazing that Chloe has now had nearly a year where not taken cocaine, and faced her debts by working part time to repay what she owes. Even better, thanks to Serenity’s fast intervention. Chloe is on course for a 2:1 in her law degree.

If you’re ready to detox? Serenity Addiction Centre’s addiction support team are here to help you find the rehab programme which works for you. Serenity can help you beat your addiction. Gaining control over drugs, allowing you to move on and take back control of your life.

This Drug Addiction Case Study is here so others may identify. Contact us today , and begin your detox journey with Serenity Addiction Centres.

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